- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.67 / $849.67 / $849.67
| Professional | | $849.67 | $849.67 | $849.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.00 / $1,813.00 / $2,647.00
| Professional | | $1,511.00 | $1,813.00 | $2,647.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.39 / $1,400.11 / $1,879.65
| Professional | | $997.39 | $1,400.11 | $1,879.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.25 / $1,873.31 / $2,979.25
| Professional | | $1,130.25 | $1,873.31 | $2,979.25 |