- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.61 / $701.33 / $1,000.40
| Professional | | $645.61 | $701.33 | $1,000.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.75 / $1,203.23 / $1,203.23
| Professional | | $1,022.75 | $1,203.23 | $1,203.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.31 / $173.31 / $1,082.51
| Facility | | $173.31 | $173.31 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.31 / $920.13 / $1,082.51
| Professional | | $173.31 | $920.13 | $1,082.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.09 / $1,010.81 / $1,684.68
| Professional | | $748.09 | $1,010.81 | $1,684.68 |