- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.10 / $634.10 / $634.10
| Professional | | $634.10 | $634.10 | $634.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.00 / $1,489.00 / $1,861.00
| Professional | | $1,241.00 | $1,489.00 | $1,861.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.26 / $1,065.09 / $1,476.14
| Professional | | $853.26 | $1,065.09 | $1,476.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $10,167.24 / $10,877.00
| Facility | | $2,607.00 | $10,167.24 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.19 / $1,595.27 / $2,468.39
| Professional | | $771.19 | $1,595.27 | $2,468.39 |