- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,265.80 / $6,165.95
| Professional | | $3,467.37 | $4,265.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,311.31 / $3,981.07
| Professional | | $2,818.38 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,165.95 / $8,709.64
| Professional | | $4,897.79 | $6,165.95 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,025.60 / $8,511.38
| Professional | | $5,011.87 | $6,025.60 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,677.35 / $6,760.83
| Professional | | $3,467.37 | $4,677.35 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $9,120.11
| Professional | | $4,265.80 | $5,623.41 | $9,120.11 |