- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.93 / $1,694.58 / $8,382.58
| Professional | | $1,539.93 | $1,694.58 | $8,382.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,018.88 / $2,018.88 / $5,735.08
| Professional | | $2,018.88 | $2,018.88 | $5,735.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.47 / $2,668.76 / $5,735.08
| Professional | | $1,410.47 | $2,668.76 | $5,735.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.71 / $2,610.77 / $5,735.08
| Professional | | $1,721.71 | $2,610.77 | $5,735.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.58 / $2,263.65 / $7,039.17
| Professional | | $1,778.58 | $2,263.65 | $7,039.17 |