- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,951.21 / $4,570.88
| Professional | | $181.97 | $2,951.21 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $467.74 / $6,165.95
| Professional | | $213.80 | $467.74 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $3,715.35 / $5,888.44
| Professional | | $223.87 | $3,715.35 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,011.87 / $26,915.35
| Professional | | $3,388.44 | $5,011.87 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $2,884.03 / $5,370.32
| Professional | | $190.55 | $2,884.03 | $5,370.32 |