- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.88 / $1,515.68 / $2,348.77
| Professional | | $1,416.88 | $1,515.68 | $2,348.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.13 / $2,018.23 / $2,962.70
| Professional | | $1,631.13 | $2,018.23 | $2,962.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.86 / $2,348.77 / $3,304.33
| Professional | | $1,932.86 | $2,348.77 | $3,304.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.78 / $1,926.62 / $2,997.82
| Professional | | $1,730.78 | $1,926.62 | $2,997.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.88 / $1,730.93 / $2,348.77
| Professional | | $1,416.88 | $1,730.93 | $2,348.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.78 / $2,290.61 / $3,012.39
| Professional | | $1,730.78 | $2,290.61 | $3,012.39 |