- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $3,235.94
| Professional | | $741.31 | $1,202.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $3,235.94
| Professional | | $1,548.82 | $1,819.70 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,380.38 / $1,995.26
| Professional | | $831.76 | $1,380.38 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $3,235.94
| Professional | | $1,479.11 | $1,479.11 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $3,715.35
| Professional | | $912.01 | $1,202.26 | $3,715.35 |