- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.35 / $1,877.52 / $1,877.52
| Professional | | $60.35 | $1,877.52 | $1,877.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.33 / $88.33 / $88.33
| Facility | | $88.33 | $88.33 | $88.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,152.87 / $4,885.72 / $4,885.72
| Professional | | $4,152.87 | $4,885.72 | $4,885.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.61 / $88.33 / $7,015.88
| Facility | | $54.61 | $88.33 | $7,015.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.49 / $3,429.42 / $6,100.75
| Professional | | $107.49 | $3,429.42 | $6,100.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,017.29 / $3,358.87 / $3,659.21
| Professional | | $3,017.29 | $3,358.87 | $3,659.21 |