- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.83 / $782.34 / $1,623.80
| Professional | | $617.83 | $782.34 | $1,623.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.14 / $1,089.26 / $3,337.89
| Professional | | $897.14 | $1,089.26 | $3,337.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.68 / $932.74 / $2,215.73
| Professional | | $658.68 | $932.74 | $2,215.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.20 / $1,125.40 / $2,215.73
| Professional | | $819.20 | $1,125.40 | $2,215.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.20 / $1,092.27 / $3,175.30
| Professional | | $819.20 | $1,092.27 | $3,175.30 |