- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.75 / $237.63 / $5,823.77
| Professional | | $172.75 | $237.63 | $5,823.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.89 / $345.80 / $5,223.04
| Facility | | $98.89 | $345.80 | $5,223.04 |
- 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
- $3,121.74 / $3,121.74 / $3,671.00
| Facility | | $3,121.74 | $3,121.74 | $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
- $107.59 / $3,016.51 / $3,435.58
| Professional | | $107.59 | $3,016.51 | $3,435.58 |