- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,263.12 / $4,263.12 / $4,263.12
| Professional | | $4,263.12 | $4,263.12 | $4,263.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.88 / $5,470.13 / $8,643.75
| Professional | | $585.88 | $5,470.13 | $8,643.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.36 / $2,968.52 / $4,706.19
| Professional | | $1,683.36 | $2,968.52 | $4,706.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,763.88 / $2,924.52 / $6,185.70
| Professional | | $2,763.88 | $2,924.52 | $6,185.70 |