- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,449.10 / $3,082.05 / $3,324.46
| Professional | | $2,449.10 | $3,082.05 | $3,324.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,410.03 / $4,011.80 / $5,068.92
| Professional | | $3,410.03 | $4,011.80 | $5,068.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $4,536.46
| Facility | | $4,536.46 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $4,536.46 / $4,536.46
| Professional | | $3,855.99 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.42 / $3,572.91 / $4,660.68
| Professional | | $2,527.42 | $3,572.91 | $4,660.68 |