- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.02 / $897.67 / $3,001.15
| Professional | | $580.02 | $897.67 | $3,001.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,957.13 / $21,231.41 / $23,257.66
| Facility | | $4,957.13 | $21,231.41 | $23,257.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.71 / $952.80 / $2,665.12
| Professional | | $584.71 | $952.80 | $2,665.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.60 / $1,199.49 / $2,665.12
| Professional | | $784.60 | $1,199.49 | $2,665.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.42 / $1,342.25 / $3,271.14
| Professional | | $994.42 | $1,342.25 | $3,271.14 |