- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.54 / $571.54 / $571.54
| Professional | | $571.54 | $571.54 | $571.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.00 / $1,242.00 / $1,813.00
| Professional | | $1,035.00 | $1,242.00 | $1,813.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.60 / $960.55 / $1,323.32
| Professional | | $770.60 | $960.55 | $1,323.32 |
- 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
- $890.45 / $1,431.74 / $2,222.87
| Professional | | $890.45 | $1,431.74 | $2,222.87 |