- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.12 / $448.58 / $1,543.95
| Professional | | $250.12 | $448.58 | $1,543.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,287.06 / $2,287.06 / $2,929.05
| Facility | | $2,287.06 | $2,287.06 | $2,929.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.88 / $1,547.59 / $3,049.50
| Professional | | $1,312.88 | $1,547.59 | $3,049.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.96 / $729.41 / $2,929.31
| Professional | | $392.96 | $729.41 | $2,929.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.96 / $559.86 / $2,239.69
| Professional | | $392.96 | $559.86 | $2,239.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.00 / $1,790.25 / $3,742.92
| Professional | | $886.00 | $1,790.25 | $3,742.92 |