- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.14 / $318.57 / $1,951.00
| Professional | | $274.14 | $318.57 | $1,951.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,371.03 / $4,371.03 / $4,371.03
| Professional | | $4,371.03 | $4,371.03 | $4,371.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.40 / $1,921.31 / $4,371.03
| Professional | | $343.40 | $1,921.31 | $4,371.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.40 / $1,921.31 / $4,371.03
| Professional | | $343.40 | $1,921.31 | $4,371.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.90 / $2,370.46 / $5,364.95
| Professional | | $1,792.90 | $2,370.46 | $5,364.95 |