- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.48 / $1,842.48 / $1,842.48
| Professional | | $1,842.48 | $1,842.48 | $1,842.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,916.64 / $4,916.64 / $4,916.64
| Professional | | $4,916.64 | $4,916.64 | $4,916.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.34 / $2,300.16 / $4,916.64
| Professional | | $2,007.34 | $2,300.16 | $4,916.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.34 / $2,300.16 / $4,916.64
| Professional | | $2,007.34 | $2,300.16 | $4,916.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.12 / $2,025.30 / $6,034.64
| Professional | | $1,892.12 | $2,025.30 | $6,034.64 |