- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,174.90 / $2,691.53
| Professional | | $1,071.52 | $1,174.90 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $3,388.44
| Professional | | $2,344.23 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $2,511.89
| Professional | | $1,445.44 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,888.44 / $14,125.38
| Facility | | $4,168.69 | $5,888.44 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,089.30 / $3,801.89
| Professional | | $1,258.93 | $2,089.30 | $3,801.89 |