- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,600.40 / $10,600.40 / $10,825.40
| Facility | | $10,600.40 | $10,600.40 | $10,825.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,325.33 / $10,214.42 / $12,667.03
| Professional | | $7,325.33 | $10,214.42 | $12,667.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,061.26 / $2,061.26 / $2,061.26
| Facility | | $2,061.26 | $2,061.26 | $2,061.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,192.81 / $9,154.96 / $11,276.66
| Professional | | $8,192.81 | $9,154.96 | $11,276.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,694.63 / $10,694.63 / $10,694.63
| Facility | | $10,694.63 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.04 / $10,694.63 / $10,694.63
| Professional | | $1,292.04 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.81 / $5,669.89 / $9,115.60
| Professional | | $4,073.81 | $5,669.89 | $9,115.60 |