- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,279.75 / $4,392.53 / $4,392.53
| Professional | | $3,279.75 | $4,392.53 | $4,392.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Facility | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,082.75 / $3,626.76 / $3,626.76
| Professional | | $3,082.75 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Facility | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Professional | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.95 / $3,501.40 / $3,908.30
| Professional | | $1,235.95 | $3,501.40 | $3,908.30 |