- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $1,980.61
| Professional | | $1,961.00 | $1,961.00 | $1,980.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.00 / $1,961.00 / $1,961.00
| Professional | | $1,961.00 | $1,961.00 | $1,961.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,135.08 / $2,454.11 / $2,822.23
| Professional | | $2,135.08 | $2,454.11 | $2,822.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.10 / $2,353.19 / $2,745.40
| Professional | | $2,157.10 | $2,353.19 | $2,745.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,928.16 / $1,961.00 / $2,941.50
| Professional | | $1,928.16 | $1,961.00 | $2,941.50 |