- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.19 / $1,590.28 / $2,972.66
| Professional | | $1,119.19 | $1,590.28 | $2,972.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,391.00 / $3,391.00 / $3,391.00
| Professional | | $3,391.00 | $3,391.00 | $3,391.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.14 / $2,362.42 / $3,395.00
| Professional | | $1,457.14 | $2,362.42 | $3,395.00 |
- 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
- $1,282.98 / $1,768.16 / $3,948.41
| Professional | | $1,282.98 | $1,768.16 | $3,948.41 |