- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.36 / $2,935.67 / $4,548.80
| Professional | | $162.36 | $2,935.67 | $4,548.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.34 / $3,483.94 / $10,931.62
| Professional | | $211.34 | $3,483.94 | $10,931.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.56 / $5,271.37 / $6,473.79
| Professional | | $391.56 | $5,271.37 | $6,473.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.59 / $3,753.08 / $6,909.36
| Professional | | $170.59 | $3,753.08 | $6,909.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.03 / $4,647.78 / $9,338.67
| Professional | | $2,049.03 | $4,647.78 | $9,338.67 |