- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.69 / $2,350.00 / $3,846.52
| Professional | | $1,865.69 | $2,350.00 | $3,846.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.62 / $3,201.47 / $4,797.87
| Professional | | $2,572.62 | $3,201.47 | $4,797.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,207.00 / $3,335.22 / $5,301.19
| Professional | | $2,207.00 | $3,335.22 | $5,301.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,824.65 / $3,637.91 / $5,580.75
| Professional | | $2,824.65 | $3,637.91 | $5,580.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,134.90 / $2,350.00 / $3,958.13
| Professional | | $2,134.90 | $2,350.00 | $3,958.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.06 / $3,036.40 / $4,940.02
| Professional | | $2,152.06 | $3,036.40 | $4,940.02 |