- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,538.36 / $3,709.98 / $3,709.98
| Professional | | $2,538.36 | $3,709.98 | $3,709.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,637.97 / $4,079.80 / $5,711.91
| Professional | | $3,637.97 | $4,079.80 | $5,711.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,192.06 / $4,561.45 / $6,385.51
| Professional | | $3,192.06 | $4,561.45 | $6,385.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,333.44 / $4,293.18 / $6,585.98
| Professional | | $3,333.44 | $4,293.18 | $6,585.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,538.36 / $3,709.98 / $3,709.98
| Professional | | $2,538.36 | $3,709.98 | $3,709.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,164.60 / $4,482.59 / $5,789.03
| Professional | | $3,164.60 | $4,482.59 | $5,789.03 |