- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.22 / $1,613.22 / $1,613.22
| Professional | | $1,613.22 | $1,613.22 | $1,613.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.12 / $2,103.89 / $2,398.42
| Professional | | $1,870.12 | $2,103.89 | $2,398.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.95 / $1,661.84 / $6,752.36
| Professional | | $1,238.95 | $1,661.84 | $6,752.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,337.65 / $2,805.18 / $3,506.48
| Professional | | $2,337.65 | $2,805.18 | $3,506.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.81 / $1,051.94 / $1,893.24
| Professional | | $981.81 | $1,051.94 | $1,893.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.83 / $1,858.43 / $1,858.43
| Professional | | $1,168.83 | $1,858.43 | $1,858.43 |