- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $455.43 / $2,257.67
| Professional | | $455.43 | $455.43 | $2,257.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $5,645.70 / $6,373.77
| Facility | | $0.02 | $5,645.70 | $6,373.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,648.06 / $3,648.06 / $3,648.06
| Professional | | $3,648.06 | $3,648.06 | $3,648.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,141.05 / $8,141.05 / $8,141.05
| Facility | | $8,141.05 | $8,141.05 | $8,141.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.36 / $1,651.95 / $3,971.01
| Professional | | $1,156.36 | $1,651.95 | $3,971.01 |