- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,378.42 / $4,378.42 / $4,378.42
| Professional | | $4,378.42 | $4,378.42 | $4,378.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.57 / $4,483.93 / $4,483.93
| Professional | | $1,127.57 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.00 / $1,855.00 / $1,942.41
| Professional | | $1,855.00 | $1,855.00 | $1,942.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.76 / $1,002.29 / $1,044.05
| Professional | | $918.76 | $1,002.29 | $1,044.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.57 / $5,275.21 / $7,912.82
| Professional | | $1,127.57 | $5,275.21 | $7,912.82 |