- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.75 / $436.75 / $557.87
| Professional | | $436.75 | $436.75 | $557.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.00 / $2,066.00 / $2,604.00
| Professional | | $1,278.00 | $2,066.00 | $2,604.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.29 / $708.87 / $1,036.04
| Professional | | $545.29 | $708.87 | $1,036.04 |
- 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
- $579.33 / $1,074.74 / $1,756.29
| Professional | | $579.33 | $1,074.74 | $1,756.29 |