- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.31 / $3,204.62 / $3,204.62
| Professional | | $1,121.31 | $3,204.62 | $3,204.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,300.53 / $3,617.00 / $3,617.00
| Professional | | $3,300.53 | $3,617.00 | $3,617.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,394.55 / $3,204.62 / $4,751.76
| Professional | | $2,394.55 | $3,204.62 | $4,751.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,799.47 / $3,116.23 / $4,848.85
| Professional | | $2,799.47 | $3,116.23 | $4,848.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.31 / $3,204.62 / $3,204.62
| Professional | | $1,121.31 | $3,204.62 | $3,204.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,116.23 / $5,462.48 / $6,805.66
| Professional | | $3,116.23 | $5,462.48 | $6,805.66 |