- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.25 / $919.25 / $919.25
| Professional | | $919.25 | $919.25 | $919.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,693.00 / $4,353.00 / $5,224.00
| Professional | | $2,693.00 | $4,353.00 | $5,224.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.97 / $1,282.45 / $1,852.43
| Professional | | $949.97 | $1,282.45 | $1,852.43 |
- 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
- $979.61 / $1,832.57 / $3,155.11
| Professional | | $979.61 | $1,832.57 | $3,155.11 |