- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.92 / $926.59 / $4,657.14
| Professional | | $455.92 | $926.59 | $4,657.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,341.06 / $9,341.06 / $11,602.02
| Facility | | $9,341.06 | $9,341.06 | $11,602.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.36 / $1,335.56 / $3,260.20
| Professional | | $696.36 | $1,335.56 | $3,260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.21 / $1,335.56 / $3,260.20
| Professional | | $1,002.21 | $1,335.56 | $3,260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.16 / $1,244.28 / $4,001.54
| Professional | | $1,002.16 | $1,244.28 | $4,001.54 |