- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.50 / $1,263.78 / $1,263.78
| Professional | | $1,240.50 | $1,263.78 | $1,263.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.67 / $1,882.12 / $3,752.66
| Professional | | $1,596.67 | $1,882.12 | $3,752.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.22 / $1,805.16 / $2,349.87
| Professional | | $1,151.22 | $1,805.16 | $2,349.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.97 / $1,560.97 / $2,349.87
| Professional | | $1,089.97 | $1,560.97 | $2,349.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.17 / $1,475.92 / $4,290.60
| Professional | | $1,206.17 | $1,475.92 | $4,290.60 |