- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.47 / $701.38 / $1,030.01
| Professional | | $137.47 | $701.38 | $1,030.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,720.78 / $4,720.78 / $5,100.08
| Facility | | $4,720.78 | $4,720.78 | $5,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.89 / $993.89 / $2,372.00
| Professional | | $993.89 | $993.89 | $2,372.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.00 / $546.32 / $2,372.00
| Professional | | $192.00 | $546.32 | $2,372.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.44 / $1,067.67 / $2,372.00
| Professional | | $210.44 | $1,067.67 | $2,372.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.56 / $1,147.51 / $2,911.37
| Professional | | $946.56 | $1,147.51 | $2,911.37 |