- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.39 / $990.39 / $990.39
| Professional | | $990.39 | $990.39 | $990.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.00 / $2,542.00 / $3,050.00
| Professional | | $2,255.00 | $2,542.00 | $3,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.06 / $1,372.53 / $2,113.66
| Professional | | $1,266.06 | $1,372.53 | $2,113.66 |
- 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
- $1,170.51 / $3,068.99 / $3,759.36
| Professional | | $1,170.51 | $3,068.99 | $3,759.36 |