- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.10 / $387.75 / $1,584.84
| Professional | | $337.10 | $387.75 | $1,584.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,994.67 / $1,994.67 / $1,994.67
| Professional | | $1,994.67 | $1,994.67 | $1,994.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.97 / $1,813.57 / $4,661.29
| Professional | | $444.97 | $1,813.57 | $4,661.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.97 / $1,813.57 / $4,661.29
| Professional | | $444.97 | $1,813.57 | $4,661.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.65 / $1,864.00 / $5,721.21
| Professional | | $1,657.65 | $1,864.00 | $5,721.21 |