- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.25 / $390.25 / $390.25
| Professional | | $390.25 | $390.25 | $390.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.00 / $1,007.00 / $1,208.00
| Professional | | $893.00 | $1,007.00 | $1,208.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.48 / $613.15 / $1,027.30
| Professional | | $598.48 | $613.15 | $1,027.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.38 / $1,343.11 / $1,768.78
| Professional | | $479.38 | $1,343.11 | $1,768.78 |