- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.80 / $1,465.55 / $3,142.63
| Professional | | $666.80 | $1,465.55 | $3,142.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.00 / $1,937.00 / $1,937.00
| Professional | | $1,937.00 | $1,937.00 | $1,937.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.83 / $1,796.69 / $3,378.48
| Professional | | $883.83 | $1,796.69 | $3,378.48 |
- 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
- $1,424.35 / $1,910.32 / $3,569.33
| Professional | | $1,424.35 | $1,910.32 | $3,569.33 |