- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.46 / $954.64 / $3,151.20
| Professional | | $233.46 | $954.64 | $3,151.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,459.10 / $4,459.10 / $4,817.39
| Facility | | $4,459.10 | $4,459.10 | $4,817.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.38 / $1,636.71 / $4,650.29
| Professional | | $1,297.38 | $1,636.71 | $4,650.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.19 / $1,015.92 / $4,650.29
| Professional | | $300.19 | $1,015.92 | $4,650.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.07 / $1,258.45 / $4,650.29
| Professional | | $324.07 | $1,258.45 | $4,650.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.77 / $1,581.86 / $5,707.71
| Professional | | $1,314.77 | $1,581.86 | $5,707.71 |