- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,705.35 / $8,705.35 / $15,245.40
| Professional | | $8,705.35 | $8,705.35 | $15,245.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17,002.59 / $17,002.59 / $17,002.59
| Professional | | $17,002.59 | $17,002.59 | $17,002.59 |
- 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
- $10,694.63 / $10,694.63 / $10,694.63
| Professional | | $10,694.63 | $10,694.63 | $10,694.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,171.60 / $4,922.04 / $7,414.50
| Professional | | $4,171.60 | $4,922.04 | $7,414.50 |