- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.22 / $673.45 / $1,002.91
| Professional | | $657.22 | $673.45 | $1,002.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.00 / $2,310.00 / $3,574.00
| Professional | | $1,925.00 | $2,310.00 | $3,574.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.08 / $1,225.67 / $1,627.52
| Professional | | $753.08 | $1,225.67 | $1,627.52 |
- 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
- $762.70 / $1,374.75 / $2,816.87
| Professional | | $762.70 | $1,374.75 | $2,816.87 |