- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.98 / $803.98 / $803.98
| Professional | | $803.98 | $803.98 | $803.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.00 / $2,080.00 / $2,496.00
| Professional | | $1,844.00 | $2,080.00 | $2,496.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.18 / $1,136.59 / $1,897.94
| Professional | | $1,122.18 | $1,136.59 | $1,897.94 |
- 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
- $1,272.70 / $2,608.98 / $3,223.45
| Professional | | $1,272.70 | $2,608.98 | $3,223.45 |