- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,486.65 / $5,486.65 / $9,842.20
| Professional | | $5,486.65 | $5,486.65 | $9,842.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,653.70 / $10,653.70 / $10,653.70
| Professional | | $10,653.70 | $10,653.70 | $10,653.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,860.06 / $7,860.06 / $7,860.06
| Facility | | $7,860.06 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,860.06 / $7,860.06 / $7,860.06
| Professional | | $7,860.06 | $7,860.06 | $7,860.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,989.95 / $3,533.58 / $5,314.10
| Professional | | $2,989.95 | $3,533.58 | $5,314.10 |