- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.37 / $924.21 / $5,100.18
| Professional | | $739.37 | $924.21 | $5,100.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $615.27 / $3,808.74 / $3,963.07
| Facility | | $615.27 | $3,808.74 | $3,963.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,118.00 / $11,564.19 / $11,564.19
| Professional | | $4,118.00 | $11,564.19 | $11,564.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,118.00 / $4,118.00 / $4,118.00
| Facility | | $4,118.00 | $4,118.00 | $4,118.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.13 / $3,631.78 / $4,180.00
| Professional | | $705.13 | $3,631.78 | $4,180.00 |