- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,175.77 / $6,175.77 / $6,175.77
| Professional | | $6,175.77 | $6,175.77 | $6,175.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.35 / $837.51 / $1,606.29
| Professional | | $638.35 | $837.51 | $1,606.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,745.50 / $8,745.50 / $8,745.50
| Professional | | $8,745.50 | $8,745.50 | $8,745.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,341.00
| Professional | | $32.34 | $32.34 | $1,341.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.05 / $793.05 / $793.05
| Professional | | $793.05 | $793.05 | $793.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.21 / $1,087.61 / $1,822.53
| Professional | | $1,011.21 | $1,087.61 | $1,822.53 |