- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,636.20 / $1,636.20 / $2,346.00
| Professional | | $1,636.20 | $1,636.20 | $2,346.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.83 / $1,866.48 / $2,100.40
| Professional | | $1,656.83 | $1,866.48 | $2,100.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $2,628.00
| Facility | | $1,350.00 | $1,350.00 | $2,628.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.56 / $1,350.00 / $1,833.30
| Professional | | $209.56 | $1,350.00 | $1,833.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.81 / $2,130.81 / $2,130.81
| Professional | | $2,130.81 | $2,130.81 | $2,130.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.22 / $1,636.20 / $2,346.00
| Professional | | $906.22 | $1,636.20 | $2,346.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.04 / $2,130.81 / $4,064.03
| Professional | | $889.04 | $2,130.81 | $4,064.03 |