- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.13 / $680.86 / $847.36
| Professional | | $656.13 | $680.86 | $847.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.00 / $1,638.00 / $2,638.00
| Professional | | $1,365.00 | $1,638.00 | $2,638.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.53 / $1,335.79 / $1,681.35
| Professional | | $890.53 | $1,335.79 | $1,681.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.60 / $1,164.64 / $2,479.11
| Professional | | $817.60 | $1,164.64 | $2,479.11 |