- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.19 / $1,348.19 / $1,348.19
| Professional | | $1,348.19 | $1,348.19 | $1,348.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,424.20 / $3,424.20 / $3,424.20
| Professional | | $3,424.20 | $3,424.20 | $3,424.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.85 / $1,621.86 / $3,424.20
| Professional | | $1,498.85 | $1,621.86 | $3,424.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.85 / $1,621.86 / $3,424.20
| Professional | | $1,498.85 | $1,621.86 | $3,424.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.03 / $1,488.33 / $4,202.82
| Professional | | $1,325.03 | $1,488.33 | $4,202.82 |