- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.87 / $643.32 / $2,917.88
| Professional | | $448.87 | $643.32 | $2,917.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,094.04 / $5,094.04 / $6,327.01
| Facility | | $5,094.04 | $5,094.04 | $6,327.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.83 / $715.83 / $843.81
| Professional | | $715.83 | $715.83 | $843.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.74 / $984.77 / $2,118.58
| Professional | | $606.74 | $984.77 | $2,118.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.05 / $984.77 / $2,118.58
| Professional | | $709.05 | $984.77 | $2,118.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.05 / $782.36 / $2,600.33
| Professional | | $651.05 | $782.36 | $2,600.33 |