- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.00 / $2,178.64 / $2,178.64
| Professional | | $1,631.00 | $2,178.64 | $2,178.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,166.10 / $2,557.73 / $3,370.05
| Professional | | $2,166.10 | $2,557.73 | $3,370.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.05 / $2,678.65 / $3,766.55
| Professional | | $2,205.05 | $2,678.65 | $3,766.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.89 / $2,535.76 / $3,890.00
| Professional | | $1,968.89 | $2,535.76 | $3,890.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,631.00 / $2,178.64 / $2,178.64
| Professional | | $1,631.00 | $2,178.64 | $2,178.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.54 / $2,616.63 / $3,426.83
| Professional | | $2,169.54 | $2,616.63 | $3,426.83 |