- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,167.07 / $4,298.58 / $4,298.58
| Professional | | $3,167.07 | $4,298.58 | $4,298.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,976.00 / $3,671.59 / $5,406.74
| Professional | | $2,976.00 | $3,671.59 | $5,406.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,234.97 / $4,298.58 / $6,015.15
| Professional | | $3,234.97 | $4,298.58 | $6,015.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,148.66 / $3,504.94 / $5,453.69
| Professional | | $3,148.66 | $3,504.94 | $5,453.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,167.07 / $4,298.58 / $4,298.58
| Professional | | $3,167.07 | $4,298.58 | $4,298.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,848.79 / $4,182.32 / $5,453.69
| Professional | | $2,848.79 | $4,182.32 | $5,453.69 |