- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,893.95 / $5,249.20 / $5,554.45
| Professional | | $3,893.95 | $5,249.20 | $5,554.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,856.61 / $6,856.61 / $6,856.61
| Professional | | $6,856.61 | $6,856.61 | $6,856.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,978.93 / $4,978.93 / $4,978.93
| Facility | | $4,978.93 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,232.09 / $4,978.93 / $4,978.93
| Professional | | $4,232.09 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.04 / $4,839.96 / $8,808.50
| Professional | | $2,769.04 | $4,839.96 | $8,808.50 |