- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.04 / $1,526.80 / $1,632.63
| Professional | | $1,408.04 | $1,526.80 | $1,632.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,123.00 / $5,123.00 / $5,123.00
| Professional | | $5,123.00 | $5,123.00 | $5,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,701.87 / $7,701.87 / $7,701.87
| Facility | | $7,701.87 | $7,701.87 | $7,701.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.21 / $2,017.83 / $3,454.51
| Professional | | $1,564.21 | $2,017.83 | $3,454.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.60 / $1,880.52 / $3,401.31
| Professional | | $1,402.60 | $1,880.52 | $3,401.31 |