- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,956.87 / $34,534.90 / $34,534.90
| Professional | | $9,956.87 | $34,534.90 | $34,534.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,121.18 / $16,757.32 / $16,757.32
| Facility | | $8,121.18 | $16,757.32 | $16,757.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,121.18 / $16,757.32 / $16,757.32
| Professional | | $8,121.18 | $16,757.32 | $16,757.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,673.27 / $15,959.35 / $16,757.32
| Facility | | $6,673.27 | $15,959.35 | $16,757.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,993.54 / $12,577.10 / $16,769.47
| Professional | | $11,993.54 | $12,577.10 | $16,769.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,397.10 / $5,971.46 / $9,201.83
| Professional | | $5,397.10 | $5,971.46 | $9,201.83 |