- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.84 / $3,000.89 / $4,500.01
| Professional | | $166.84 | $3,000.89 | $4,500.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.51 / $694.48 / $6,857.33
| Professional | | $209.51 | $694.48 | $6,857.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.70 / $2,572.58 / $7,241.21
| Professional | | $254.70 | $2,572.58 | $7,241.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,964.37 / $27,106.76 / $29,285.40
| Professional | | $12,964.37 | $27,106.76 | $29,285.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,699.63 / $5,711.68 / $8,309.37
| Professional | | $3,699.63 | $5,711.68 | $8,309.37 |