- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.81 / $943.81 / $1,682.98
| Professional | | $943.81 | $943.81 | $1,682.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.22 / $1,257.88 / $1,979.52
| Professional | | $1,097.22 | $1,257.88 | $1,979.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.27 / $1,412.48 / $2,023.63
| Professional | | $1,172.27 | $1,412.48 | $2,023.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.43 / $1,351.57 / $2,073.38
| Professional | | $1,049.43 | $1,351.57 | $2,073.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.81 / $943.81 / $1,682.98
| Professional | | $943.81 | $943.81 | $1,682.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.17 / $1,595.54 / $2,072.11
| Professional | | $1,168.17 | $1,595.54 | $2,072.11 |