- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.90 / $942.07 / $3,719.33
| Professional | | $360.90 | $942.07 | $3,719.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,684.00 / $4,684.00 / $4,684.00
| Professional | | $4,684.00 | $4,684.00 | $4,684.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.92 / $1,586.34 / $4,399.26
| Professional | | $548.92 | $1,586.34 | $4,399.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.45 / $2,773.95 / $5,866.41
| Professional | | $1,390.45 | $2,773.95 | $5,866.41 |