- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.89 / $2,205.00 / $3,360.27
| Professional | | $169.89 | $2,205.00 | $3,360.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.71 / $2,311.80 / $7,994.48
| Professional | | $166.71 | $2,311.80 | $7,994.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,144.06 / $3,853.01 / $5,548.34
| Professional | | $3,144.06 | $3,853.01 | $5,548.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.42 / $4,140.76 / $7,932.13
| Professional | | $227.42 | $4,140.76 | $7,932.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,586.59 / $4,648.13 / $7,137.86
| Professional | | $3,586.59 | $4,648.13 | $7,137.86 |