- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.73 / $1,039.30 / $1,049.67
| Professional | | $706.73 | $1,039.30 | $1,049.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.01 / $1,014.01 / $1,014.01
| Professional | | $1,014.01 | $1,014.01 | $1,014.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $795.00 / $795.00 / $810.90
| Facility | | $795.00 | $795.00 | $810.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.75 / $795.00 / $810.90
| Professional | | $675.75 | $795.00 | $810.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.24 / $668.58 / $847.60
| Professional | | $514.24 | $668.58 | $847.60 |