- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,258.93 / $3,235.94
| Professional | | $1,148.15 | $1,258.93 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,630.78 / $4,365.16
| Professional | | $2,454.71 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,187.76 / $3,019.95
| Professional | | $1,584.89 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $26,915.35
| Facility | | $8,511.38 | $8,511.38 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,570.40 / $4,265.80
| Professional | | $1,380.38 | $2,570.40 | $4,265.80 |