- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $2,951.21
| Professional | | $933.25 | $1,148.15 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $2,187.76
| Professional | | $1,071.52 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $2,344.23
| Professional | | $1,071.52 | $1,412.54 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $3,311.31
| Professional | | $933.25 | $1,318.26 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,148.15
| Professional | | $933.25 | $933.25 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,511.89
| Professional | | $1,096.48 | $1,479.11 | $2,511.89 |