- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.11 / $2,313.00 / $2,313.00
| Professional | | $1,704.11 | $2,313.00 | $2,313.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.25 / $1,972.03 / $2,922.74
| Professional | | $1,597.25 | $1,972.03 | $2,922.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,904.86 / $2,313.00 / $3,238.65
| Professional | | $1,904.86 | $2,313.00 | $3,238.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.16 / $1,882.52 / $2,929.20
| Professional | | $1,691.16 | $1,882.52 | $2,929.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.11 / $2,313.00 / $2,313.00
| Professional | | $1,704.11 | $2,313.00 | $2,313.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.46 / $2,176.55 / $2,626.87
| Professional | | $1,832.46 | $2,176.55 | $2,626.87 |