- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.28 / $2,027.71 / $3,486.47
| Professional | | $429.28 | $2,027.71 | $3,486.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.62 / $1,156.83 / $5,357.00
| Facility | | $277.62 | $1,156.83 | $5,357.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,022.45 / $5,211.74 / $12,762.92
| Professional | | $3,022.45 | $5,211.74 | $12,762.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $493.35 / $3,021.23 / $4,137.07
| Facility | | $493.35 | $3,021.23 | $4,137.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $449.78 / $2,600.42 / $4,977.21
| Professional | | $449.78 | $2,600.42 | $4,977.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.84 / $1,964.79 / $4,225.93
| Professional | | $339.84 | $1,964.79 | $4,225.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.94 / $3,500.42 / $5,445.10
| Professional | | $1,861.94 | $3,500.42 | $5,445.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.40 / $504.50 / $2,917.00
| Professional | | $412.40 | $504.50 | $2,917.00 |