- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.71 / $3,234.85 / $3,234.85
| Professional | | $1,640.71 | $3,234.85 | $3,234.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,010.53 / $14,279.49 / $16,101.93
| Facility | | $11,010.53 | $14,279.49 | $16,101.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.32 / $2,789.86 / $4,089.20
| Professional | | $2,263.32 | $2,789.86 | $4,089.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.33 / $3,234.85 / $4,576.60
| Professional | | $1,783.33 | $3,234.85 | $4,576.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,392.51 / $2,663.22 / $4,143.97
| Professional | | $2,392.51 | $2,663.22 | $4,143.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.71 / $3,234.85 / $3,234.85
| Professional | | $1,640.71 | $3,234.85 | $3,234.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,749.37 / $3,007.76 / $4,158.21
| Professional | | $1,749.37 | $3,007.76 | $4,158.21 |