- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.99 / $1,395.80 / $2,588.73
| Professional | | $1,012.99 | $1,395.80 | $2,588.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.00 / $2,492.00 / $2,492.00
| Professional | | $2,492.00 | $2,492.00 | $2,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.59 / $2,071.78 / $3,027.74
| Professional | | $1,311.59 | $2,071.78 | $3,027.74 |
- 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
- $1,232.26 / $1,668.13 / $3,290.49
| Professional | | $1,232.26 | $1,668.13 | $3,290.49 |