- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.54 / $2,666.54 / $2,666.54
| Professional | | $2,666.54 | $2,666.54 | $2,666.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $15,547.75 / $17,552.79
| Facility | | $0.02 | $15,547.75 | $17,552.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,046.42 / $10,046.42 / $10,046.42
| Professional | | $10,046.42 | $10,046.42 | $10,046.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,418.59 / $22,418.59 / $22,418.59
| Facility | | $22,418.59 | $22,418.59 | $22,418.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,184.52 / $4,549.32 / $10,935.81
| Professional | | $3,184.52 | $4,549.32 | $10,935.81 |