- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.80 / $795.62 / $1,294.08
| Professional | | $660.80 | $795.62 | $1,294.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.00 / $287.00 / $287.00
| Professional | | $287.00 | $287.00 | $287.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.20 / $248.40 / $398.20
| Professional | | $221.20 | $248.40 | $398.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.42 / $2,404.55 / $12,000.00
| Facility | | $500.42 | $2,404.55 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.41 / $956.41 / $956.41
| Professional | | $956.41 | $956.41 | $956.41 |