- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,691.53 / $5,623.41
| Professional | | $181.97 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $407.38 / $4,897.79
| Professional | | $223.87 | $407.38 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $3,890.45 / $6,025.60
| Professional | | $204.17 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $467.74 / $7,762.47
| Professional | | $223.87 | $467.74 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,754.40 / $26,915.35
| Professional | | $3,548.13 | $5,754.40 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $3,090.30 / $5,754.40
| Professional | | $199.53 | $3,090.30 | $5,754.40 |