- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,640.42 / $3,640.42 / $6,375.36
| Professional | | $3,640.42 | $3,640.42 | $6,375.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,110.20 / $7,110.20 / $7,110.20
| Facility | | $7,110.20 | $7,110.20 | $7,110.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,110.20 / $7,110.20 / $7,110.20
| Professional | | $7,110.20 | $7,110.20 | $7,110.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,790.37 / $3,790.37 / $7,497.68
| Facility | | $3,790.37 | $3,790.37 | $7,497.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.97 / $2,766.97 / $3,790.37
| Professional | | $2,766.97 | $2,766.97 | $3,790.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,735.17 / $3,026.25 / $4,663.35
| Professional | | $2,735.17 | $3,026.25 | $4,663.35 |