- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.58 / $2,337.00 / $2,337.00
| Professional | | $320.58 | $2,337.00 | $2,337.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.80 / $2,804.40 / $3,197.02
| Professional | | $2,492.80 | $2,804.40 | $3,197.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.00 / $2,215.28 / $9,000.62
| Professional | | $1,706.00 | $2,215.28 | $9,000.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,116.00 / $3,739.20 / $4,674.00
| Professional | | $3,116.00 | $3,739.20 | $4,674.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.72 / $1,402.20 / $2,804.40
| Professional | | $1,308.72 | $1,402.20 | $2,804.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.00 / $2,447.21 / $2,447.21
| Professional | | $1,558.00 | $2,447.21 | $2,447.21 |