- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $2,348.57 / $2,348.57
| Professional | | $1,861.53 | $2,348.57 | $2,348.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.95 / $2,003.55 / $3,125.88
| Professional | | $1,633.95 | $2,003.55 | $3,125.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.93 / $2,348.57 / $3,276.18
| Professional | | $1,974.93 | $2,348.57 | $3,276.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.19 / $1,912.61 / $2,976.02
| Professional | | $1,718.19 | $1,912.61 | $2,976.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $2,348.57 / $2,348.57
| Professional | | $1,861.53 | $2,348.57 | $2,348.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.65 / $2,345.87 / $2,964.98
| Professional | | $1,787.65 | $2,345.87 | $2,964.98 |