- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,780.62 / $5,209.20 / $5,209.20
| Professional | | $3,780.62 | $5,209.20 | $5,209.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,603.60 / $4,428.10 / $6,580.71
| Professional | | $3,603.60 | $4,428.10 | $6,580.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,363.35 / $5,209.20 / $7,274.45
| Professional | | $4,363.35 | $5,209.20 | $7,274.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,797.43 / $4,227.10 / $6,577.38
| Professional | | $3,797.43 | $4,227.10 | $6,577.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,555.51 / $3,780.62 / $5,209.20
| Professional | | $3,555.51 | $3,780.62 | $5,209.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,777.11 / $5,199.32 / $6,590.91
| Professional | | $3,777.11 | $5,199.32 | $6,590.91 |