- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.59 / $1,785.70 / $1,785.70
| Professional | | $1,337.59 | $1,785.70 | $1,785.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.94 / $1,949.94 / $2,774.24
| Professional | | $1,766.94 | $1,949.94 | $2,774.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.84 / $2,195.54 / $3,098.73
| Professional | | $1,699.84 | $2,195.54 | $3,098.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.28 / $2,089.37 / $3,205.20
| Professional | | $1,622.28 | $2,089.37 | $3,205.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.59 / $1,785.70 / $1,785.70
| Professional | | $1,337.59 | $1,785.70 | $1,785.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.22 / $2,276.83 / $2,827.13
| Professional | | $1,734.22 | $2,276.83 | $2,827.13 |