- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $2,951.21 / $4,786.30
| Professional | | $177.83 | $2,951.21 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $616.60 / $7,762.47
| Professional | | $234.42 | $616.60 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $3,715.35 / $7,079.46
| Professional | | $257.04 | $3,715.35 | $7,079.46 |
- 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 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $3,162.28 / $7,079.46
| Professional | | $204.17 | $3,162.28 | $7,079.46 |