- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,917.73 / $3,565.30 / $4,820.85
| Professional | | $2,917.73 | $3,565.30 | $4,820.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,338.16 / $4,085.69 / $6,112.79
| Professional | | $3,338.16 | $4,085.69 | $6,112.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,646.01 / $4,820.85 / $6,745.62
| Professional | | $3,646.01 | $4,820.85 | $6,745.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,503.78 / $3,900.24 / $6,068.77
| Professional | | $3,503.78 | $3,900.24 | $6,068.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,917.73 / $4,507.29 / $5,687.33
| Professional | | $2,917.73 | $4,507.29 | $5,687.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,950.62 / $4,565.01 / $6,091.97
| Professional | | $2,950.62 | $4,565.01 | $6,091.97 |