- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.02 / $3,136.95 / $3,136.95
| Professional | | $2,102.02 | $3,136.95 | $3,136.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,173.31 / $2,675.86 / $3,967.99
| Professional | | $2,173.31 | $2,675.86 | $3,967.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,642.29 / $3,136.95 / $4,391.83
| Professional | | $2,642.29 | $3,136.95 | $4,391.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.75 / $2,554.40 / $3,974.65
| Professional | | $2,294.75 | $2,554.40 | $3,974.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.02 / $3,136.95 / $3,136.95
| Professional | | $2,102.02 | $3,136.95 | $3,136.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.96 / $3,120.46 / $3,986.63
| Professional | | $2,238.96 | $3,120.46 | $3,986.63 |