- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.31 / $372.31 / $2,416.67
| Professional | | $372.31 | $372.31 | $2,416.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,439.32 / $5,439.32 / $5,439.32
| Professional | | $5,439.32 | $5,439.32 | $5,439.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.98 / $2,398.85 / $5,439.32
| Professional | | $407.98 | $2,398.85 | $5,439.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.98 / $2,398.85 / $5,439.32
| Professional | | $407.98 | $2,398.85 | $5,439.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,214.75 / $2,699.55 / $6,676.16
| Professional | | $2,214.75 | $2,699.55 | $6,676.16 |