- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,396.75 / $6,396.75 / $11,202.50
| Professional | | $6,396.75 | $6,396.75 | $11,202.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,493.70 / $12,493.70 / $12,493.70
| Professional | | $12,493.70 | $12,493.70 | $12,493.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Facility | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,109.46 / $5,109.46 / $5,109.46
| Professional | | $5,109.46 | $5,109.46 | $5,109.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,065.37 / $3,616.80 / $5,448.30
| Professional | | $3,065.37 | $3,616.80 | $5,448.30 |