- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.76 / $501.22 / $2,621.00
| Professional | | $75.76 | $501.22 | $2,621.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,537.31 / $1,604.45 / $7,175.98
| Facility | | $1,537.31 | $1,604.45 | $7,175.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.34 / $701.34 / $1,448.38
| Professional | | $701.34 | $701.34 | $1,448.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.33 / $332.91 / $1,448.38
| Professional | | $117.33 | $332.91 | $1,448.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.22 / $649.23 / $1,448.38
| Professional | | $138.22 | $649.23 | $1,448.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.47 / $788.23 / $1,777.73
| Professional | | $670.47 | $788.23 | $1,777.73 |