- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,563.92 / $4,563.92 / $4,563.92
| Professional | | $4,563.92 | $4,563.92 | $4,563.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,447.14 / $7,447.14 / $7,447.14
| Facility | | $7,447.14 | $7,447.14 | $7,447.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.86 / $7,447.14 / $14,055.00
| Professional | | $856.86 | $7,447.14 | $14,055.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,020.27 / $3,427.44 / $6,711.70
| Professional | | $3,020.27 | $3,427.44 | $6,711.70 |