- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,889.74 / $3,889.74 / $3,889.74
| Professional | | $3,889.74 | $3,889.74 | $3,889.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,200.00 / $8,640.00 / $12,610.00
| Professional | | $7,200.00 | $8,640.00 | $12,610.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,626.10 / $6,626.10 / $6,626.10
| Professional | | $6,626.10 | $6,626.10 | $6,626.10 |
- 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
- $5,918.54 / $8,931.62 / $14,204.53
| Professional | | $5,918.54 | $8,931.62 | $14,204.53 |