- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,340.21 / $4,991.60 / $5,124.62
| Professional | | $3,340.21 | $4,991.60 | $5,124.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,545.71 / $4,357.72 / $6,474.52
| Professional | | $3,545.71 | $4,357.72 | $6,474.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,314.72 / $5,124.62 / $7,157.64
| Professional | | $4,314.72 | $5,124.62 | $7,157.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,737.07 / $4,159.92 / $6,472.84
| Professional | | $3,737.07 | $4,159.92 | $6,472.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,340.21 / $4,991.60 / $5,124.62
| Professional | | $3,340.21 | $4,991.60 | $5,124.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,057.00 / $5,115.05 / $6,472.84
| Professional | | $4,057.00 | $5,115.05 | $6,472.84 |