- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.19 / $1,625.12 / $1,625.12
| Professional | | $692.19 | $1,625.12 | $1,625.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,380.94 / $3,380.94 / $3,380.94
| Professional | | $3,380.94 | $3,380.94 | $3,380.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.27 / $3,380.94 / $3,380.94
| Professional | | $1,133.27 | $3,380.94 | $3,380.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.27 / $3,380.94 / $3,380.94
| Professional | | $1,133.27 | $3,380.94 | $3,380.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.69 / $1,245.60 / $4,149.72
| Professional | | $978.69 | $1,245.60 | $4,149.72 |