- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,457.51 / $4,457.51 / $4,457.51
| Professional | | $4,457.51 | $4,457.51 | $4,457.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,121.00 / $10,945.00 / $17,620.00
| Professional | | $9,121.00 | $10,945.00 | $17,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,863.60 / $7,359.53 / $10,831.26
| Professional | | $5,863.60 | $7,359.53 | $10,831.26 |
- 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
- $6,560.40 / $13,120.80 / $17,623.32
| Professional | | $6,560.40 | $13,120.80 | $17,623.32 |