- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,191.82 / $3,191.82 / $3,191.82
| Professional | | $3,191.82 | $3,191.82 | $3,191.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,288.00 / $8,218.00 / $9,862.00
| Professional | | $7,288.00 | $8,218.00 | $9,862.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,500.52 / $4,545.26 / $7,667.21
| Professional | | $4,500.52 | $4,545.26 | $7,667.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,315.88 / $10,022.10 / $12,785.51
| Professional | | $4,315.88 | $10,022.10 | $12,785.51 |