- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.65 / $944.65 / $944.65
| Professional | | $944.65 | $944.65 | $944.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.00 / $2,047.00 / $2,988.00
| Professional | | $1,706.00 | $2,047.00 | $2,988.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.53 / $1,581.20 / $2,219.36
| Professional | | $1,283.53 | $1,581.20 | $2,219.36 |
- 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
- $1,510.30 / $2,452.64 / $3,717.12
| Professional | | $1,510.30 | $2,452.64 | $3,717.12 |