- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.91 / $1,155.99 / $2,680.19
| Professional | | $1,067.91 | $1,155.99 | $2,680.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.00 / $1,934.00 / $1,934.00
| Professional | | $1,934.00 | $1,934.00 | $1,934.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.86 / $1,936.80 / $2,649.07
| Professional | | $1,127.86 | $1,936.80 | $2,649.07 |
- 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
- $1,039.11 / $1,377.15 / $2,867.48
| Professional | | $1,039.11 | $1,377.15 | $2,867.48 |