- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.31 / $1,008.31 / $1,008.31
| Professional | | $1,008.31 | $1,008.31 | $1,008.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.00 / $2,328.00 / $2,794.00
| Professional | | $1,746.00 | $2,328.00 | $2,794.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.42 / $1,270.22 / $1,905.32
| Professional | | $840.42 | $1,270.22 | $1,905.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.92 / $1,638.61 / $2,956.83
| Professional | | $981.92 | $1,638.61 | $2,956.83 |