- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.36 / $403.47 / $5,242.43
| Professional | | $338.36 | $403.47 | $5,242.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,864.97 / $4,864.97 / $12,826.48
| Professional | | $4,864.97 | $4,864.97 | $12,826.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.86 / $5,629.51 / $12,826.48
| Professional | | $436.86 | $5,629.51 | $12,826.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.86 / $5,629.51 / $12,826.48
| Professional | | $436.86 | $5,629.51 | $12,826.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,332.97 / $5,995.79 / $15,743.07
| Professional | | $4,332.97 | $5,995.79 | $15,743.07 |