- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.51 / $981.97 / $981.97
| Professional | | $964.51 | $981.97 | $981.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.20 / $1,458.20 / $2,918.54
| Professional | | $1,458.20 | $1,458.20 | $2,918.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.49 / $1,393.93 / $1,819.36
| Professional | | $895.49 | $1,393.93 | $1,819.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.86 / $1,207.97 / $1,819.36
| Professional | | $843.86 | $1,207.97 | $1,819.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.00 / $1,142.71 / $3,321.93
| Professional | | $1,022.00 | $1,142.71 | $3,321.93 |