- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.45 / $2,063.02 / $2,730.47
| Professional | | $1,653.45 | $2,063.02 | $2,730.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,695.30 / $3,695.30 / $4,427.39
| Professional | | $3,695.30 | $3,695.30 | $4,427.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.92 / $2,578.78 / $2,651.83
| Professional | | $1,325.92 | $2,578.78 | $2,651.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.84 / $1,274.22 / $4,083.58
| Professional | | $1,061.84 | $1,274.22 | $4,083.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.14 / $1,820.32 / $1,820.32
| Professional | | $819.14 | $1,820.32 | $1,820.32 |