- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $3,388.44
| Professional | | $758.58 | $1,096.48 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,174.90 / $2,951.21
| Professional | | $1,122.02 | $1,174.90 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Professional | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $2,398.83
| Professional | | $1,122.02 | $1,584.89 | $2,398.83 |