- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $741.31 / $4,466.84
| Professional | | $165.96 | $741.31 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $457.09 / $6,456.54
| Professional | | $194.98 | $457.09 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $645.65 / $10,964.78
| Professional | | $263.03 | $645.65 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $4,365.16 / $10,000.00
| Professional | | $234.42 | $4,365.16 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $4,365.16 / $10,232.93
| Professional | | $275.42 | $4,365.16 | $10,232.93 |