- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $3,311.31 / $5,370.32
| Professional | | $707.95 | $3,311.31 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $3,162.28 / $5,248.07
| Professional | | $741.31 | $3,162.28 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,398.83 / $5,495.41
| Professional | | $891.25 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,365.16 / $29,512.09
| Professional | | $3,090.30 | $4,365.16 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $2,454.71 / $4,570.88
| Professional | | $707.95 | $2,454.71 | $4,570.88 |