- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.11 / $804.11 / $804.11
| Professional | | $804.11 | $804.11 | $804.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.00 / $1,782.00 / $2,674.00
| Professional | | $1,485.00 | $1,782.00 | $2,674.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.18 / $1,331.25 / $1,836.49
| Professional | | $1,072.18 | $1,331.25 | $1,836.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.90 / $1,977.06 / $3,153.49
| Professional | | $1,197.90 | $1,977.06 | $3,153.49 |