- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.74 / $228.74 / $228.74
| Professional | | $228.74 | $228.74 | $228.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,405.80 / $21,144.87 / $33,649.15
| Facility | | $13,405.80 | $21,144.87 | $33,649.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.38 / $1,301.69 / $2,551.94
| Professional | | $240.38 | $1,301.69 | $2,551.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.48 / $1,940.00 / $11,315.00
| Facility | | $262.48 | $1,940.00 | $11,315.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.62 / $2,948.16 / $12,762.92
| Professional | | $1,670.62 | $2,948.16 | $12,762.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.35 / $2,496.11 / $3,646.08
| Professional | | $1,572.35 | $2,496.11 | $3,646.08 |