- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,071.52 / $3,162.28
| Professional | | $630.96 | $1,071.52 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $3,630.78
| Professional | | $1,148.15 | $1,148.15 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,202.26 / $1,819.70
| Professional | | $691.83 | $1,202.26 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $1,698.24
| Professional | | $1,047.13 | $1,380.38 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $2,398.83
| Professional | | $812.83 | $1,148.15 | $2,398.83 |