- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.76 / $575.77 / $3,569.16
| Professional | | $482.76 | $575.77 | $3,569.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,213.82 / $4,213.82 / $10,158.50
| Professional | | $4,213.82 | $4,213.82 | $10,158.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.75 / $4,470.72 / $10,158.50
| Professional | | $628.75 | $4,470.72 | $10,158.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.75 / $4,470.72 / $10,158.50
| Professional | | $628.75 | $4,470.72 | $10,158.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,074.12 / $4,684.95 / $12,468.42
| Professional | | $4,074.12 | $4,684.95 | $12,468.42 |