- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,983.65 / $2,983.65 / $5,184.70
| Professional | | $2,983.65 | $2,983.65 | $5,184.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,811.10 / $5,811.10 / $5,811.10
| Professional | | $5,811.10 | $5,811.10 | $5,811.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $5,765.22
| Facility | | $1,642.21 | $1,642.21 | $5,765.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Professional | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.33 / $2,938.92 / $4,422.63
| Professional | | $2,488.33 | $2,938.92 | $4,422.63 |