- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.14 / $545.14 / $545.14
| Professional | | $545.14 | $545.14 | $545.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.00 / $989.00 / $1,187.00
| Professional | | $828.00 | $989.00 | $1,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.66 / $904.36 / $1,106.63
| Professional | | $617.66 | $904.36 | $1,106.63 |
- 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
- $698.51 / $1,174.46 / $1,877.02
| Professional | | $698.51 | $1,174.46 | $1,877.02 |