- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.42 / $727.42 / $727.42
| Professional | | $727.42 | $727.42 | $727.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.00 / $1,609.00 / $2,414.00
| Professional | | $1,341.00 | $1,609.00 | $2,414.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.88 / $1,204.22 / $1,751.30
| Professional | | $929.88 | $1,204.22 | $1,751.30 |
- 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
- $1,040.60 / $1,435.55 / $2,756.18
| Professional | | $1,040.60 | $1,435.55 | $2,756.18 |