- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.50 / $425.82 / $1,967.90
| Professional | | $278.50 | $425.82 | $1,967.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,693.70 / $9,693.70 / $10,659.60
| Facility | | $9,693.70 | $9,693.70 | $10,659.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.44 / $2,313.27 / $6,025.82
| Professional | | $1,962.44 | $2,313.27 | $6,025.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.62 / $1,684.30 / $4,138.41
| Professional | | $479.62 | $1,684.30 | $4,138.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.91 / $2,139.12 / $3,651.76
| Professional | | $510.91 | $2,139.12 | $3,651.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,172.39 / $2,508.83 / $7,396.02
| Professional | | $2,172.39 | $2,508.83 | $7,396.02 |