- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,884.03 / $6,165.95
| Professional | | $181.97 | $2,884.03 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $831.76 / $5,623.41
| Professional | | $169.82 | $831.76 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $3,311.31 / $7,079.46
| Professional | | $204.17 | $3,311.31 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $26,915.35
| Professional | | $3,467.37 | $5,011.87 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $3,090.30 / $5,888.44
| Professional | | $190.55 | $3,090.30 | $5,888.44 |