- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,386.10 / $2,386.10 / $4,845.39
| Professional | | $2,386.10 | $2,386.10 | $4,845.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,633.20 / $4,633.20 / $4,633.20
| Professional | | $4,633.20 | $4,633.20 | $4,633.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $3,470.68
| Professional | | $2,673.00 | $2,673.00 | $3,470.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.24 / $2,046.12 / $3,410.20
| Professional | | $1,783.24 | $2,046.12 | $3,410.20 |