- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.53 / $1,179.53 / $1,179.53
| Professional | | $1,179.53 | $1,179.53 | $1,179.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.92 / $1,309.07 / $8,500.00
| Professional | | $1,273.92 | $1,309.07 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.39 / $2,037.83 / $3,346.87
| Professional | | $1,157.39 | $2,037.83 | $3,346.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.81 / $2,595.98 / $2,595.98
| Professional | | $1,253.81 | $2,595.98 | $2,595.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.05 / $1,579.99 / $3,143.03
| Professional | | $1,003.05 | $1,579.99 | $3,143.03 |