- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.93 / $1,532.96 / $2,807.50
| Professional | | $1,076.93 | $1,532.96 | $2,807.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,312.00 / $3,312.00 / $3,312.00
| Professional | | $3,312.00 | $3,312.00 | $3,312.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.84 / $2,307.54 / $3,313.00
| Professional | | $1,407.84 | $2,307.54 | $3,313.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.64 / $1,912.81 / $3,812.86
| Professional | | $1,368.64 | $1,912.81 | $3,812.86 |