- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,744.00 / $9,744.00 / $9,744.00
| Professional | | $9,744.00 | $9,744.00 | $9,744.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.03 / $1,251.36 / $1,430.31
| Professional | | $1,121.03 | $1,251.36 | $1,430.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,922.63 / $2,865.00 / $7,114.08
| Professional | | $1,922.63 | $2,865.00 | $7,114.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.20 / $1,512.81 / $2,532.05
| Professional | | $1,169.20 | $1,512.81 | $2,532.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.41 / $1,413.67 / $2,435.54
| Professional | | $934.41 | $1,413.67 | $2,435.54 |