- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.09 / $1,163.38 / $1,163.38
| Professional | | $849.09 | $1,163.38 | $1,163.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.72 / $1,054.08 / $1,054.08
| Professional | | $963.72 | $1,054.08 | $1,054.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.87 / $109.87 / $111.27
| Facility | | $109.87 | $109.87 | $111.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.39 / $109.87 / $147.10
| Professional | | $93.39 | $109.87 | $147.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.98 / $1,163.38 / $1,163.38
| Professional | | $816.98 | $1,163.38 | $1,163.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.63 / $194.32 / $825.37
| Professional | | $64.63 | $194.32 | $825.37 |