- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.90 / $433.12 / $2,288.11
| Professional | | $372.90 | $433.12 | $2,288.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,652.44 / $4,536.50 / $5,189.82
| Facility | | $3,652.44 | $4,536.50 | $5,189.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,918.27 / $2,918.27 / $3,961.39
| Professional | | $2,918.27 | $2,918.27 | $3,961.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.91 / $1,773.35 / $3,961.39
| Professional | | $385.91 | $1,773.35 | $3,961.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.91 / $1,773.35 / $3,961.39
| Professional | | $385.91 | $1,773.35 | $3,961.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.05 / $2,564.96 / $4,862.16
| Professional | | $1,854.05 | $2,564.96 | $4,862.16 |