- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.42 / $3,060.31 / $3,060.31
| Professional | | $1,959.42 | $3,060.31 | $3,060.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.12 / $2,612.39 / $3,873.06
| Professional | | $2,122.12 | $2,612.39 | $3,873.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.79 / $3,060.31 / $4,288.27
| Professional | | $2,208.79 | $3,060.31 | $4,288.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.32 / $2,493.81 / $3,880.37
| Professional | | $2,240.32 | $2,493.81 | $3,880.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.42 / $3,060.31 / $3,060.31
| Professional | | $1,959.42 | $3,060.31 | $3,060.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.54 / $3,044.88 / $3,674.86
| Professional | | $2,070.54 | $3,044.88 | $3,674.86 |