- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.00 / $252.00 / $315.00
| Professional | | $252.00 | $252.00 | $315.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,841.28 / $19,841.28 / $19,841.28
| Facility | | $19,841.28 | $19,841.28 | $19,841.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,762.65 / $3,762.65 / $3,762.65
| Professional | | $3,762.65 | $3,762.65 | $3,762.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.30 / $329.62 / $456.76
| Facility | | $294.30 | $329.62 | $456.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.30 / $398.20 / $574.61
| Professional | | $294.30 | $398.20 | $574.61 |