- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.29 / $575.29 / $575.29
| Professional | | $575.29 | $575.29 | $575.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,680.00 / $2,716.00 / $3,259.00
| Professional | | $1,680.00 | $2,716.00 | $3,259.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.69 / $758.28 / $1,095.29
| Professional | | $561.69 | $758.28 | $1,095.29 |
- 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
- $560.86 / $1,109.58 / $1,740.70
| Professional | | $560.86 | $1,109.58 | $1,740.70 |