- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.25 / $2,044.44 / $2,044.44
| Professional | | $1,760.25 | $2,044.44 | $2,044.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.75 / $1,728.49 / $2,899.09
| Professional | | $1,414.75 | $1,728.49 | $2,899.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.45 / $2,157.44 / $2,855.69
| Professional | | $1,721.45 | $2,157.44 | $2,855.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.31 / $1,650.04 / $2,567.46
| Professional | | $1,482.31 | $1,650.04 | $2,567.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.25 / $2,044.44 / $2,044.44
| Professional | | $1,760.25 | $2,044.44 | $2,044.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,822.25 / $2,271.82 / $2,741.85
| Professional | | $1,822.25 | $2,271.82 | $2,741.85 |