- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $2,951.21 / $5,888.44
| Professional | | $186.21 | $2,951.21 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $1,288.25 / $6,918.31
| Professional | | $251.19 | $1,288.25 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $524.81 / $7,413.10
| Professional | | $251.19 | $524.81 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $5,888.44 / $15,848.93
| Professional | | $269.15 | $5,888.44 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $3,548.13 / $4,265.80
| Professional | | $190.55 | $3,548.13 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $3,715.35 / $7,413.10
| Professional | | $257.04 | $3,715.35 | $7,413.10 |