- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,106.37 / $4,106.37 / $4,106.37
| Professional | | $4,106.37 | $4,106.37 | $4,106.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,601.00 / $9,121.00 / $13,313.00
| Professional | | $7,601.00 | $9,121.00 | $13,313.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,995.11 / $6,995.11 / $6,995.11
| Professional | | $6,995.11 | $6,995.11 | $6,995.11 |
- 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
- $6,248.00 / $7,896.56 / $14,995.19
| Professional | | $6,248.00 | $7,896.56 | $14,995.19 |