- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.02 / $622.84 / $2,418.98
| Professional | | $305.02 | $622.84 | $2,418.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,484.68 / $6,108.66 / $7,587.24
| Facility | | $4,484.68 | $6,108.66 | $7,587.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.92 / $2,254.17 / $7,943.27
| Professional | | $300.92 | $2,254.17 | $7,943.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.27 / $2,302.41 / $7,943.27
| Professional | | $403.27 | $2,302.41 | $7,943.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,212.38 / $2,815.75 / $9,749.48
| Professional | | $2,212.38 | $2,815.75 | $9,749.48 |