- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.80 / $924.80 / $924.80
| Professional | | $924.80 | $924.80 | $924.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.00 / $2,168.00 / $2,711.00
| Professional | | $1,807.00 | $2,168.00 | $2,711.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.53 / $1,549.32 / $2,167.60
| Professional | | $1,255.53 | $1,549.32 | $2,167.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.60 / $2,883.21 / $3,616.80
| Professional | | $1,458.60 | $2,883.21 | $3,616.80 |