- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.94 / $817.94 / $817.94
| Professional | | $817.94 | $817.94 | $817.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $1,219.64
| Facility | | $1,219.64 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.18 / $1,219.64 / $3,465.00
| Professional | | $211.18 | $1,219.64 | $3,465.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.30 / $1,788.67 / $2,189.38
| Professional | | $1,014.30 | $1,788.67 | $2,189.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.10 / $1,240.54 / $1,817.65
| Professional | | $224.10 | $1,240.54 | $1,817.65 |