- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,670.30 / $3,576.30 / $3,576.30
| Professional | | $2,670.30 | $3,576.30 | $3,576.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.91 / $2,671.66 / $2,671.66
| Professional | | $2,270.91 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Professional | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.76 / $2,100.73 / $3,182.30
| Professional | | $935.76 | $2,100.73 | $3,182.30 |