- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.47 / $518.05 / $2,859.04
| Professional | | $444.47 | $518.05 | $2,859.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,665.93 / $6,290.35 / $6,290.35
| Professional | | $3,665.93 | $6,290.35 | $6,290.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.77 / $2,790.08 / $6,290.35
| Professional | | $564.77 | $2,790.08 | $6,290.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.77 / $2,790.08 / $6,290.35
| Professional | | $564.77 | $2,790.08 | $6,290.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,629.26 / $3,176.09 / $7,720.70
| Professional | | $2,629.26 | $3,176.09 | $7,720.70 |