- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.40 / $1,080.10 / $14,932.80
| Professional | | $210.40 | $1,080.10 | $14,932.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.68 / $329.68 / $329.68
| Facility | | $329.68 | $329.68 | $329.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.68 / $342.22 / $4,122.31
| Professional | | $329.68 | $342.22 | $4,122.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.44 / $3,504.15 / $3,786.15
| Facility | | $203.44 | $3,504.15 | $3,786.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.41 / $2,225.60 / $4,122.31
| Professional | | $219.41 | $2,225.60 | $4,122.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,340.70 / $4,580.77 / $6,488.87
| Professional | | $3,340.70 | $4,580.77 | $6,488.87 |