- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.64 / $1,882.66 / $1,882.66
| Professional | | $1,631.64 | $1,882.66 | $1,882.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,008.17 / $2,259.19 / $2,575.48
| Professional | | $2,008.17 | $2,259.19 | $2,575.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.23 / $1,478.23 / $1,478.23
| Professional | | $1,478.23 | $1,478.23 | $1,478.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,510.21 / $3,012.25 / $3,765.32
| Professional | | $2,510.21 | $3,012.25 | $3,765.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,255.10 / $2,284.23
| Professional | | $1,054.29 | $1,255.10 | $2,284.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.10 / $1,255.10 / $1,255.10
| Professional | | $1,255.10 | $1,255.10 | $1,255.10 |