- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.34 / $875.34 / $875.34
| Professional | | $875.34 | $875.34 | $875.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,566.00 / $4,148.00 / $4,978.00
| Professional | | $2,566.00 | $4,148.00 | $4,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.32 / $1,203.28 / $1,738.07
| Professional | | $891.32 | $1,203.28 | $1,738.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.98 / $1,727.39 / $2,736.48
| Professional | | $873.98 | $1,727.39 | $2,736.48 |