- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.70 / $1,886.76 / $1,886.76
| Professional | | $1,485.70 | $1,886.76 | $1,886.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.63 / $1,615.36 / $2,377.94
| Professional | | $1,310.63 | $1,615.36 | $2,377.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.43 / $1,886.76 / $2,654.00
| Professional | | $1,538.43 | $1,886.76 | $2,654.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.29 / $1,542.04 / $2,399.41
| Professional | | $1,385.29 | $1,542.04 | $2,399.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.10 / $1,485.70 / $1,886.76
| Professional | | $1,320.10 | $1,485.70 | $1,886.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.33 / $1,779.18 / $2,300.66
| Professional | | $1,265.33 | $1,779.18 | $2,300.66 |