- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.37 / $1,220.16 / $1,610.26
| Professional | | $863.37 | $1,220.16 | $1,610.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.03 / $1,357.57 / $2,088.16
| Professional | | $1,049.03 | $1,357.57 | $2,088.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.09 / $1,399.77 / $2,170.00
| Professional | | $864.09 | $1,399.77 | $2,170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.92 / $1,510.71 / $2,238.01
| Professional | | $1,260.92 | $1,510.71 | $2,238.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.37 / $1,220.16 / $1,610.26
| Professional | | $863.37 | $1,220.16 | $1,610.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.07 / $1,281.05 / $2,006.69
| Professional | | $836.07 | $1,281.05 | $2,006.69 |