- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,584.89 / $3,715.35
| Professional | | $1,258.93 | $1,584.89 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,041.74 / $2,951.21
| Professional | | $1,258.93 | $2,041.74 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $3,090.30
| Professional | | $1,548.82 | $1,905.46 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,862.09 / $3,548.13
| Professional | | $1,548.82 | $1,862.09 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $3,801.89
| Professional | | $1,318.26 | $1,905.46 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,819.70 / $2,754.23
| Professional | | $1,174.90 | $1,819.70 | $2,754.23 |