- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.32 / $180.32 / $824.34
| Professional | | $180.32 | $180.32 | $824.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.00 / $486.00 / $1,893.00
| Professional | | $405.00 | $486.00 | $1,893.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.83 / $435.12 / $2,338.39
| Professional | | $277.83 | $435.12 | $2,338.39 |
- 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
- $1,355.73 / $2,375.44 / $3,777.85
| Professional | | $1,355.73 | $2,375.44 | $3,777.85 |