- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.60 / $224.75 / $2,581.80
| Professional | | $164.60 | $224.75 | $2,581.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,425.94 / $9,425.94 / $10,183.28
| Facility | | $9,425.94 | $9,425.94 | $10,183.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.75 / $436.21 / $4,287.12
| Professional | | $225.75 | $436.21 | $4,287.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.45 / $427.88 / $4,287.12
| Professional | | $212.45 | $427.88 | $4,287.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.26 / $2,550.35 / $7,827.80
| Professional | | $273.26 | $2,550.35 | $7,827.80 |