- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.84 / $1,496.31 / $2,727.17
| Professional | | $1,018.84 | $1,496.31 | $2,727.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,921.00 / $2,921.00 / $2,921.00
| Professional | | $2,921.00 | $2,921.00 | $2,921.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.75 / $2,176.80 / $3,118.43
| Professional | | $1,343.75 | $2,176.80 | $3,118.43 |
- 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
- $1,300.98 / $1,798.09 / $3,622.91
| Professional | | $1,300.98 | $1,798.09 | $3,622.91 |