- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.24 / $1,205.26 / $1,445.92
| Professional | | $625.24 | $1,205.26 | $1,445.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,310.00 / $2,310.00 / $2,310.00
| Professional | | $2,310.00 | $2,310.00 | $2,310.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $1,386.71
| Professional | | $742.34 | $742.34 | $1,386.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $1,546.55 / $2,706.46
| Professional | | $100.00 | $1,546.55 | $2,706.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.37 / $771.56 / $1,106.90
| Professional | | $713.37 | $771.56 | $1,106.90 |