- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.93 / $266.93 / $1,451.68
| Professional | | $234.93 | $266.93 | $1,451.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,083.09 / $4,083.09 / $5,229.24
| Facility | | $4,083.09 | $4,083.09 | $5,229.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.32 / $1,052.58 / $3,032.87
| Professional | | $309.32 | $1,052.58 | $3,032.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.91 / $1,526.08 / $2,405.23
| Professional | | $319.91 | $1,526.08 | $2,405.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.85 / $1,850.22 / $4,463.64
| Professional | | $1,430.85 | $1,850.22 | $4,463.64 |