- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.10 / $3,387.07 / $5,823.77
| Professional | | $190.10 | $3,387.07 | $5,823.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.05 / $3,141.29 / $4,351.22
| Facility | | $170.05 | $3,141.29 | $4,351.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.00 / $3,671.00 / $11,431.36
| Professional | | $173.00 | $3,671.00 | $11,431.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,874.12 / $3,121.74 / $3,671.00
| Facility | | $1,874.12 | $3,121.74 | $3,671.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.67 / $2,722.00 / $4,215.76
| Professional | | $180.67 | $2,722.00 | $4,215.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,246.39 / $4,431.00 / $6,214.50
| Professional | | $4,246.39 | $4,431.00 | $6,214.50 |