- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.98 / $4,040.11 / $4,040.11
| Professional | | $3,021.98 | $4,040.11 | $4,040.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,798.81 / $3,428.05 / $5,125.88
| Professional | | $2,798.81 | $3,428.05 | $5,125.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,091.90 / $4,040.11 / $5,658.33
| Professional | | $3,091.90 | $4,040.11 | $5,658.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,939.81 / $3,272.46 / $5,091.95
| Professional | | $2,939.81 | $3,272.46 | $5,091.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.98 / $4,040.11 / $4,040.11
| Professional | | $3,021.98 | $4,040.11 | $4,040.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,697.88 / $3,829.28 / $4,621.54
| Professional | | $2,697.88 | $3,829.28 | $4,621.54 |