- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.54 / $628.17 / $9,792.12
| Professional | | $524.54 | $628.17 | $9,792.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,087.09 / $9,087.09 / $26,551.47
| Professional | | $9,087.09 | $9,087.09 | $26,551.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.59 / $10,747.52 / $26,551.47
| Professional | | $689.59 | $10,747.52 | $26,551.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.59 / $10,747.52 / $26,551.47
| Professional | | $689.59 | $10,747.52 | $26,551.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,425.48 / $11,200.55 / $32,588.96
| Professional | | $10,425.48 | $11,200.55 | $32,588.96 |