- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $1,096.48
| Professional | | $776.25 | $776.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $776.25 / $1,148.15
| Facility | | $537.03 | $776.25 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $691.83 / $1,202.26
| Professional | | $7.94 | $691.83 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $3,235.94 / $3,235.94
| Facility | | $56.23 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |