- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.38 / $1,060.74 / $4,894.00
| Professional | | $171.38 | $1,060.74 | $4,894.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,397.73 / $6,397.73 / $7,383.85
| Facility | | $6,397.73 | $6,397.73 | $7,383.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.69 / $659.35 / $2,871.24
| Professional | | $225.69 | $659.35 | $2,871.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.42 / $1,289.49 / $2,871.24
| Professional | | $258.42 | $1,289.49 | $2,871.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.34 / $1,460.21 / $3,524.13
| Professional | | $1,255.34 | $1,460.21 | $3,524.13 |