- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.77 / $1,050.77 / $1,050.77
| Professional | | $1,050.77 | $1,050.77 | $1,050.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.80 / $1,097.70 / $1,097.70
| Professional | | $961.80 | $1,097.70 | $1,097.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $124.05 / $1,223.23
| Professional | | $124.05 | $124.05 | $1,223.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.97 / $737.97 / $1,050.77
| Professional | | $737.97 | $737.97 | $1,050.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.36 / $738.53 / $1,896.42
| Professional | | $492.36 | $738.53 | $1,896.42 |