- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.52 / $1,147.52 / $1,200.49
| Professional | | $1,147.52 | $1,147.52 | $1,200.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.29 / $1,724.90 / $3,739.21
| Professional | | $1,463.29 | $1,724.90 | $3,739.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.49 / $1,401.96 / $2,360.79
| Professional | | $1,150.49 | $1,401.96 | $2,360.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.88 / $1,447.11 / $2,360.79
| Professional | | $1,096.88 | $1,447.11 | $2,360.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.51 / $1,449.21 / $4,310.55
| Professional | | $1,296.51 | $1,449.21 | $4,310.55 |