- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,951.21 / $4,897.79
| Professional | | $181.97 | $2,951.21 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,318.26 / $11,220.18
| Professional | | $354.81 | $1,318.26 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $5,754.40 / $15,135.61
| Professional | | $467.74 | $5,754.40 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,348.96 / $13,489.63
| Professional | | $426.58 | $1,348.96 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,912.51 / $16,595.87
| Professional | | $4,897.79 | $8,912.51 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $3,981.07 / $12,882.50
| Professional | | $302.00 | $3,981.07 | $12,882.50 |