- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,745.20 / $4,745.20 / $5,931.50
| Professional | | $4,745.20 | $4,745.20 | $5,931.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,647.62 / $3,647.62 / $3,647.62
| Facility | | $3,647.62 | $3,647.62 | $3,647.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,804.60 / $8,804.60 / $8,804.60
| Professional | | $8,804.60 | $8,804.60 | $8,804.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,018.72 / $5,629.73 / $5,629.73
| Facility | | $3,018.72 | $5,629.73 | $5,629.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,018.72 / $5,629.73 / $6,414.78
| Professional | | $3,018.72 | $5,629.73 | $6,414.78 |