- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,319.05 / $3,032.53 / $3,032.53
| Professional | | $2,319.05 | $3,032.53 | $3,032.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.65 / $2,587.34 / $3,837.96
| Professional | | $2,101.65 | $2,587.34 | $3,837.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,377.44 / $3,032.53 / $4,247.52
| Professional | | $2,377.44 | $3,032.53 | $4,247.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,218.84 / $2,469.90 / $3,843.16
| Professional | | $2,218.84 | $2,469.90 | $3,843.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,319.05 / $3,032.53 / $3,032.53
| Professional | | $2,319.05 | $3,032.53 | $3,032.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.42 / $2,871.07 / $3,465.09
| Professional | | $2,023.42 | $2,871.07 | $3,465.09 |