- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,452.23 / $8,452.23 / $8,452.23
| Professional | | $8,452.23 | $8,452.23 | $8,452.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,983.81 / $11,983.81 / $11,983.81
| Facility | | $11,983.81 | $11,983.81 | $11,983.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,034.23 / $13,034.23 / $13,034.23
| Professional | | $13,034.23 | $13,034.23 | $13,034.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30,250.00 / $30,250.00 / $30,250.00
| Professional | | $30,250.00 | $30,250.00 | $30,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,729.95 / $11,983.81 / $34,688.57
| Professional | | $10,729.95 | $11,983.81 | $34,688.57 |