- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,999.46 / $4,088.88 / $4,088.88
| Professional | | $2,999.46 | $4,088.88 | $4,088.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,845.74 / $3,506.21 / $5,151.71
| Professional | | $2,845.74 | $3,506.21 | $5,151.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,321.23 / $4,088.88 / $5,760.24
| Professional | | $3,321.23 | $4,088.88 | $5,760.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,006.84 / $3,347.06 / $5,208.03
| Professional | | $3,006.84 | $3,347.06 | $5,208.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,999.46 / $4,088.88 / $4,088.88
| Professional | | $2,999.46 | $4,088.88 | $4,088.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,759.48 / $3,941.21 / $4,972.52
| Professional | | $2,759.48 | $3,941.21 | $4,972.52 |