- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.10 / $973.10 / $973.10
| Professional | | $973.10 | $973.10 | $973.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.00 / $2,155.00 / $3,232.00
| Professional | | $1,796.00 | $2,155.00 | $3,232.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.80 / $1,610.67 / $2,161.54
| Professional | | $1,256.80 | $1,610.67 | $2,161.54 |
- 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
- $1,422.29 / $2,348.06 / $3,747.49
| Professional | | $1,422.29 | $2,348.06 | $3,747.49 |