- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.25 / $1,722.25 / $3,622.30
| Professional | | $1,722.25 | $1,722.25 | $3,622.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,344.20 / $3,344.20 / $3,344.20
| Professional | | $3,344.20 | $3,344.20 | $3,344.20 |
- 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
- $1,361.32 / $1,623.00 / $2,705.00
| Professional | | $1,361.32 | $1,623.00 | $2,705.00 |