- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.26 / $567.29 / $2,997.22
| Professional | | $488.26 | $567.29 | $2,997.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,767.71 / $3,767.71 / $6,292.69
| Professional | | $3,767.71 | $3,767.71 | $6,292.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.21 / $2,833.98 / $6,292.69
| Professional | | $634.21 | $2,833.98 | $6,292.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.21 / $2,833.98 / $6,292.69
| Professional | | $634.21 | $2,833.98 | $6,292.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,665.14 / $3,516.27 / $7,723.58
| Professional | | $2,665.14 | $3,516.27 | $7,723.58 |