- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.15 / $3,469.62 / $3,469.62
| Professional | | $2,454.15 | $3,469.62 | $3,469.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.11 / $2,951.78 / $4,389.75
| Professional | | $2,403.11 | $2,951.78 | $4,389.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,552.59 / $3,469.62 / $4,852.31
| Professional | | $2,552.59 | $3,469.62 | $4,852.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,531.37 / $2,817.80 / $4,384.50
| Professional | | $2,531.37 | $2,817.80 | $4,384.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.15 / $3,469.62 / $3,469.62
| Professional | | $2,454.15 | $3,469.62 | $3,469.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.40 / $3,463.33 / $4,395.64
| Professional | | $2,299.40 | $3,463.33 | $4,395.64 |