- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,283.66 / $4,419.81 / $4,419.81
| Professional | | $3,283.66 | $4,419.81 | $4,419.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,076.60 / $3,744.99 / $5,597.06
| Professional | | $3,076.60 | $3,744.99 | $5,597.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,317.10 / $4,419.81 / $6,220.51
| Professional | | $3,317.10 | $4,419.81 | $6,220.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,211.61 / $3,575.01 / $5,562.72
| Professional | | $3,211.61 | $3,575.01 | $5,562.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,283.66 / $4,419.81 / $4,419.81
| Professional | | $3,283.66 | $4,419.81 | $4,419.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,682.47 / $4,163.83 / $5,025.32
| Professional | | $2,682.47 | $4,163.83 | $5,025.32 |