- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,248.07
| Professional | | $4,786.30 | $4,786.30 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Professional | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,754.40 / $6,760.83
| Professional | | $5,248.07 | $5,754.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,623.41 / $7,244.36
| Professional | | $4,786.30 | $5,623.41 | $7,244.36 |