- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.01 / $1,249.01 / $2,075.31
| Professional | | $1,249.01 | $1,249.01 | $2,075.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.58 / $1,782.46 / $2,616.71
| Professional | | $1,441.58 | $1,782.46 | $2,616.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.18 / $2,075.31 / $2,920.89
| Professional | | $1,707.18 | $2,075.31 | $2,920.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.60 / $1,701.56 / $2,647.63
| Professional | | $1,528.60 | $1,701.56 | $2,647.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.01 / $1,525.77 / $2,075.31
| Professional | | $1,249.01 | $1,525.77 | $2,075.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.59 / $1,957.63 / $2,663.10
| Professional | | $1,434.59 | $1,957.63 | $2,663.10 |