- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,890.45 / $6,165.95
| Professional | | $3,630.78 | $3,890.45 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,466.84 / $4,466.84
| Professional | | $3,801.89 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Professional | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $8,317.64
| Facility | | $4,168.69 | $4,168.69 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Professional | | $3,715.35 | $3,715.35 | $3,715.35 |