- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.00 / $967.97 / $1,056.78
| Professional | | $776.00 | $967.97 | $1,056.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.17 / $2,040.80 / $2,861.40
| Professional | | $1,088.17 | $2,040.80 | $2,861.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.66 / $1,487.79 / $3,122.82
| Professional | | $1,039.66 | $1,487.79 | $3,122.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.33 / $1,625.80 / $3,050.48
| Professional | | $988.33 | $1,625.80 | $3,050.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.29 / $1,376.30 / $2,401.98
| Professional | | $631.29 | $1,376.30 | $2,401.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.43 / $493.39 / $3,375.00
| Professional | | $394.43 | $493.39 | $3,375.00 |