- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,884.03 / $6,165.95
| Professional | | $2,511.89 | $2,884.03 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,606.93 / $7,943.28
| Professional | | $5,888.44 | $6,606.93 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,715.35 / $6,165.95
| Professional | | $3,630.78 | $3,715.35 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,011.87 / $9,772.37
| Professional | | $3,090.30 | $5,011.87 | $9,772.37 |