- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,483.03 / $1,483.03 / $1,560.81
| Professional | | $1,483.03 | $1,483.03 | $1,560.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.06 / $1,925.00 / $4,804.93
| Professional | | $1,633.06 | $1,925.00 | $4,804.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.68 / $1,841.37 / $3,049.35
| Professional | | $1,576.68 | $1,841.37 | $3,049.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.30 / $1,911.39 / $3,049.35
| Professional | | $1,427.30 | $1,911.39 | $3,049.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,676.61 / $1,915.24 / $5,567.75
| Professional | | $1,676.61 | $1,915.24 | $5,567.75 |