- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.77 / $1,020.87 / $1,891.27
| Professional | | $717.77 | $1,020.87 | $1,891.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.00 / $1,637.00 / $1,637.00
| Professional | | $1,637.00 | $1,637.00 | $1,637.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.68 / $1,465.76 / $2,133.84
| Professional | | $928.68 | $1,465.76 | $2,133.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.35 / $1,171.30 / $2,334.73
| Professional | | $900.35 | $1,171.30 | $2,334.73 |