- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,037.84 / $6,791.18 / $7,186.14
| Professional | | $5,037.84 | $6,791.18 | $7,186.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,870.83 / $8,870.83 / $8,870.83
| Professional | | $8,870.83 | $8,870.83 | $8,870.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,102.62 / $10,102.62 / $10,102.62
| Facility | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,587.24 / $10,102.62 / $10,102.62
| Professional | | $8,587.24 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,582.44 / $5,470.12 / $9,116.87
| Professional | | $3,582.44 | $5,470.12 | $9,116.87 |