- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,223.45 / $8,223.45 / $14,401.50
| Professional | | $8,223.45 | $8,223.45 | $14,401.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,061.40 / $16,061.40 / $16,061.40
| Professional | | $16,061.40 | $16,061.40 | $16,061.40 |
- 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
- $10,102.62 / $10,102.62 / $10,102.62
| Professional | | $10,102.62 | $10,102.62 | $10,102.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,940.68 / $4,657.17 / $7,004.10
| Professional | | $3,940.68 | $4,657.17 | $7,004.10 |