- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.63 / $1,011.60 / $3,636.66
| Professional | | $386.63 | $1,011.60 | $3,636.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,474.00 / $4,474.00 / $4,474.00
| Professional | | $4,474.00 | $4,474.00 | $4,474.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.21 / $1,550.24 / $4,256.72
| Professional | | $589.21 | $1,550.24 | $4,256.72 |
- 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
- $1,351.22 / $2,641.76 / $5,341.74
| Professional | | $1,351.22 | $2,641.76 | $5,341.74 |