- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.84 / $502.84 / $502.84
| Professional | | $502.84 | $502.84 | $502.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.00 / $1,291.00 / $1,549.00
| Professional | | $1,145.00 | $1,291.00 | $1,549.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.53 / $744.08 / $1,227.51
| Professional | | $722.53 | $744.08 | $1,227.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $6,295.00 / $14,634.00
| Facility | | $4,200.00 | $6,295.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.28 / $1,661.00 / $1,993.21
| Professional | | $715.28 | $1,661.00 | $1,993.21 |