- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,313.37 / $3,313.37 / $3,313.37
| Professional | | $3,313.37 | $3,313.37 | $3,313.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,673.00 / $8,008.00 / $12,890.00
| Professional | | $6,673.00 | $8,008.00 | $12,890.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,987.93 / $5,426.57 / $7,537.45
| Professional | | $3,987.93 | $5,426.57 | $7,537.45 |
- 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
- $4,483.60 / $10,183.77 / $12,559.81
| Professional | | $4,483.60 | $10,183.77 | $12,559.81 |