- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.70 / $922.70 / $922.70
| Professional | | $922.70 | $922.70 | $922.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.00 / $2,042.00 / $3,062.00
| Professional | | $1,702.00 | $2,042.00 | $3,062.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.93 / $1,526.31 / $2,091.90
| Professional | | $1,152.93 | $1,526.31 | $2,091.90 |
- 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
- $1,041.19 / $2,100.71 / $3,354.14
| Professional | | $1,041.19 | $2,100.71 | $3,354.14 |