- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,425.37 / $2,425.37 / $2,798.51
| Professional | | $2,425.37 | $2,425.37 | $2,798.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $2,833.27 / $3,511.67
| Professional | | $2,404.69 | $2,833.27 | $3,511.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,294.10 / $3,294.10 / $3,294.10
| Facility | | $3,294.10 | $3,294.10 | $3,294.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,404.69 / $3,294.10 / $3,511.67
| Professional | | $2,404.69 | $3,294.10 | $3,511.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.02 / $3,419.35 / $5,745.71
| Professional | | $1,653.02 | $3,419.35 | $5,745.71 |