- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.61 / $1,048.41 / $2,213.39
| Professional | | $913.61 | $1,048.41 | $2,213.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.00 / $1,681.00 / $1,681.00
| Professional | | $1,681.00 | $1,681.00 | $1,681.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.93 / $1,682.98 / $2,302.55
| Professional | | $1,029.93 | $1,682.98 | $2,302.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.64 / $1,277.06 / $2,773.75
| Professional | | $957.64 | $1,277.06 | $2,773.75 |