- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.15 / $427.15 / $623.72
| Professional | | $427.15 | $427.15 | $623.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.00 / $2,031.00 / $2,895.00
| Professional | | $1,256.00 | $2,031.00 | $2,895.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.30 / $779.01 / $1,138.56
| Professional | | $570.30 | $779.01 | $1,138.56 |
- 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
- $606.79 / $1,195.25 / $1,857.90
| Professional | | $606.79 | $1,195.25 | $1,857.90 |