- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.23 / $2,490.54 / $2,490.54
| Professional | | $1,793.23 | $2,490.54 | $2,490.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.26 / $2,137.41 / $3,142.29
| Professional | | $1,729.26 | $2,137.41 | $3,142.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,048.83 / $2,490.54 / $3,502.17
| Professional | | $2,048.83 | $2,490.54 | $3,502.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.99 / $2,040.39 / $3,174.85
| Professional | | $1,832.99 | $2,040.39 | $3,174.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.23 / $2,490.54 / $2,490.54
| Professional | | $1,793.23 | $2,490.54 | $2,490.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.88 / $2,351.32 / $3,040.50
| Professional | | $1,715.88 | $2,351.32 | $3,040.50 |