- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.85 / $1,523.16 / $1,523.16
| Professional | | $840.85 | $1,523.16 | $1,523.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.40 / $1,461.30 / $1,461.33
| Professional | | $1,120.40 | $1,461.30 | $1,461.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.19 / $144.19 / $2,067.13
| Facility | | $144.19 | $144.19 | $2,067.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.56 / $144.19 / $1,209.89
| Professional | | $122.56 | $144.19 | $1,209.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.85 / $1,069.71 / $1,523.16
| Professional | | $840.85 | $1,069.71 | $1,523.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.90 / $907.07 / $2,411.80
| Professional | | $557.90 | $907.07 | $2,411.80 |