- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.10 / $420.60 / $9,752.99
| Professional | | $190.10 | $420.60 | $9,752.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.65 / $199.70 / $4,350.09
| Facility | | $114.65 | $199.70 | $4,350.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,147.21 / $11,431.36 / $11,431.36
| Professional | | $3,147.21 | $11,431.36 | $11,431.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,874.12 / $2,408.75 / $3,671.00
| Facility | | $1,874.12 | $2,408.75 | $3,671.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.67 / $3,121.74 / $4,068.64
| Professional | | $180.67 | $3,121.74 | $4,068.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,214.50 / $6,214.50 / $6,214.50
| Professional | | $6,214.50 | $6,214.50 | $6,214.50 |