- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,176.83 / $4,176.83 / $4,176.83
| Professional | | $4,176.83 | $4,176.83 | $4,176.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,992.94 / $3,992.94 / $14,020.80
| Professional | | $3,992.94 | $3,992.94 | $14,020.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,298.10 / $7,298.10 / $7,298.10
| Professional | | $7,298.10 | $7,298.10 | $7,298.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,176.83 / $4,176.83 / $12,193.00
| Professional | | $4,176.83 | $4,176.83 | $12,193.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,872.72 / $3,006.02 / $7,587.47
| Professional | | $2,872.72 | $3,006.02 | $7,587.47 |