- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.82 / $727.82 / $727.82
| Professional | | $727.82 | $727.82 | $727.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.00 / $1,612.00 / $2,417.00
| Professional | | $1,343.00 | $1,612.00 | $2,417.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.18 / $1,205.67 / $1,605.99
| Professional | | $938.18 | $1,205.67 | $1,605.99 |
- 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
- $1,082.95 / $1,782.00 / $2,904.01
| Professional | | $1,082.95 | $1,782.00 | $2,904.01 |