- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $2,951.21 / $6,606.93
| Professional | | $186.21 | $2,951.21 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $5,370.32 / $9,772.37
| Professional | | $239.88 | $5,370.32 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $3,467.37 / $7,943.28
| Professional | | $245.47 | $3,467.37 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $8,912.51 / $10,964.78
| Professional | | $3.02 | $8,912.51 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $3,162.28 / $7,244.36
| Professional | | $199.53 | $3,162.28 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $29,512.09 / $29,512.09
| Professional | | $28,183.83 | $29,512.09 | $29,512.09 |