- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.78 / $1,091.52 / $1,351.48
| Professional | | $682.78 | $1,091.52 | $1,351.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.61 / $922.98 / $1,248.09
| Professional | | $854.61 | $922.98 | $1,248.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.59 / $816.59 / $945.33
| Facility | | $816.59 | $816.59 | $945.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.43 / $816.59 / $968.96
| Professional | | $92.43 | $816.59 | $968.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.78 / $1,091.51 / $1,351.48
| Professional | | $682.78 | $1,091.51 | $1,351.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.04 / $648.47 / $1,396.89
| Professional | | $338.04 | $648.47 | $1,396.89 |