- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.11 / $216.11 / $1,911.14
| Professional | | $216.11 | $216.11 | $1,911.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,498.58 / $4,498.58 / $4,498.58
| Professional | | $4,498.58 | $4,498.58 | $4,498.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.20 / $1,979.51 / $4,498.58
| Professional | | $237.20 | $1,979.51 | $4,498.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.20 / $1,979.51 / $4,498.58
| Professional | | $237.20 | $1,979.51 | $4,498.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,934.49 / $2,169.35 / $5,521.50
| Professional | | $1,934.49 | $2,169.35 | $5,521.50 |