- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.22 / $1,593.22 / $7,698.63
| Professional | | $1,593.22 | $1,593.22 | $7,698.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.77 / $2,006.77 / $5,282.55
| Professional | | $2,006.77 | $2,006.77 | $5,282.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.87 / $1,931.96 / $5,282.55
| Professional | | $1,515.87 | $1,931.96 | $5,282.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.02 / $1,943.70 / $5,282.55
| Professional | | $1,911.02 | $1,943.70 | $5,282.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.51 / $2,076.46 / $6,483.74
| Professional | | $1,631.51 | $2,076.46 | $6,483.74 |