- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.37 / $1,176.38 / $11,506.80
| Professional | | $278.37 | $1,176.38 | $11,506.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $350.18 / $350.18 / $350.18
| Facility | | $350.18 | $350.18 | $350.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.18 / $376.55 / $3,727.40
| Professional | | $350.18 | $376.55 | $3,727.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.13 / $2,196.94 / $2,712.79
| Facility | | $174.13 | $2,196.94 | $2,712.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.77 / $2,325.86 / $4,000.86
| Professional | | $226.77 | $2,325.86 | $4,000.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,312.92 / $3,466.66 / $5,913.58
| Professional | | $2,312.92 | $3,466.66 | $5,913.58 |