- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.28 / $597.28 / $597.28
| Professional | | $597.28 | $597.28 | $597.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.00 / $1,301.00 / $1,898.00
| Professional | | $1,084.00 | $1,301.00 | $1,898.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.65 / $1,005.90 / $1,533.60
| Professional | | $821.65 | $1,005.90 | $1,533.60 |
- 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
- $926.20 / $1,490.69 / $2,315.28
| Professional | | $926.20 | $1,490.69 | $2,315.28 |