- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $2,238.72 / $3,235.94
| Professional | | $645.65 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,344.23 / $7,413.10
| Professional | | $1,288.25 | $2,344.23 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $2,884.03 / $6,918.31
| Professional | | $954.99 | $2,884.03 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,011.87 / $10,471.29
| Facility | | $2,630.27 | $5,011.87 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $3,162.28 / $8,709.64
| Professional | | $912.01 | $3,162.28 | $8,709.64 |