- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $3,311.31
| Professional | | $1,258.93 | $2,238.72 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $4,073.80
| Professional | | $1,698.24 | $2,691.53 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $4,073.80
| Professional | | $2,398.83 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,630.27 / $3,467.37
| Professional | | $2,187.76 | $2,630.27 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $3,311.31
| Professional | | $1,949.84 | $2,630.27 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $3,630.78
| Professional | | $2,187.76 | $2,818.38 | $3,630.78 |