- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $2,951.21 / $4,466.84
| Professional | | $177.83 | $2,951.21 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $2,818.38 / $5,248.07
| Professional | | $190.55 | $2,818.38 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $4,265.80 / $27,542.29
| Professional | | $223.87 | $4,265.80 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $2,691.53 / $6,309.57
| Professional | | $186.21 | $2,691.53 | $6,309.57 |