- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,157.49 / $4,158.00 / $4,357.17
| Professional | | $4,157.49 | $4,158.00 | $4,357.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.00 / $1,984.00 / $1,984.00
| Professional | | $1,984.00 | $1,984.00 | $1,984.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.69 / $2,059.69 / $2,059.69
| Professional | | $2,059.69 | $2,059.69 | $2,059.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.45 / $1,316.81 / $2,627.85
| Professional | | $1,021.45 | $1,316.81 | $2,627.85 |