- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,495.41 / $6,760.83
| Professional | | $2,511.89 | $5,495.41 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $6,165.95
| Facility | | $3,090.30 | $3,090.30 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $3,090.30 / $10,715.19
| Professional | | $645.65 | $3,090.30 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $616.60 / $3,467.37
| Facility | | $263.03 | $616.60 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,884.03 / $5,011.87
| Professional | | $1,778.28 | $2,884.03 | $5,011.87 |