- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.71 / $188.81 / $3,096.00
| Professional | | $148.71 | $188.81 | $3,096.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,007.66 / $2,007.66 / $2,168.98
| Facility | | $2,007.66 | $2,007.66 | $2,168.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.93 / $837.57 / $3,196.19
| Professional | | $213.93 | $837.57 | $3,196.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.04 / $1,359.93 / $3,196.19
| Professional | | $251.04 | $1,359.93 | $3,196.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.24 / $1,453.58 / $3,922.97
| Professional | | $1,357.24 | $1,453.58 | $3,922.97 |