- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.78 / $2,894.00 / $3,944.81
| Professional | | $177.78 | $2,894.00 | $3,944.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.44 / $2,878.33 / $6,224.38
| Professional | | $212.44 | $2,878.33 | $6,224.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.81 / $2,376.21 / $4,931.00
| Professional | | $2,217.81 | $2,376.21 | $4,931.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.07 / $3,774.62 / $5,174.89
| Professional | | $2,464.07 | $3,774.62 | $5,174.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,108.37 / $4,680.93 / $7,655.64
| Professional | | $3,108.37 | $4,680.93 | $7,655.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.37 / $239.82 / $239.82
| Professional | | $161.37 | $239.82 | $239.82 |