- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.12 / $1,135.43 / $2,139.51
| Professional | | $883.12 | $1,135.43 | $2,139.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.00 / $1,779.00 / $1,779.00
| Professional | | $1,779.00 | $1,779.00 | $1,779.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.44 / $1,783.19 / $2,368.12
| Professional | | $1,096.44 | $1,783.19 | $2,368.12 |
- 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
- $1,009.86 / $1,313.33 / $2,520.48
| Professional | | $1,009.86 | $1,313.33 | $2,520.48 |