- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.49 / $626.49 / $793.83
| Professional | | $626.49 | $626.49 | $793.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.00 / $1,441.00 / $1,824.00
| Professional | | $1,081.00 | $1,441.00 | $1,824.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.54 / $951.54 / $1,384.57
| Professional | | $703.54 | $951.54 | $1,384.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.63 / $1,318.80 / $2,379.75
| Professional | | $803.63 | $1,318.80 | $2,379.75 |