- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.58 / $887.58 / $887.58
| Professional | | $887.58 | $887.58 | $887.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.00 / $2,080.00 / $2,600.00
| Professional | | $1,733.00 | $2,080.00 | $2,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.43 / $1,486.69 / $2,065.69
| Professional | | $1,201.43 | $1,486.69 | $2,065.69 |
- 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
- $1,390.40 / $2,229.39 / $3,458.42
| Professional | | $1,390.40 | $2,229.39 | $3,458.42 |