- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $2,511.89 / $5,011.87
| Professional | | $158.49 | $2,511.89 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $676.08 / $8,709.64
| Professional | | $281.84 | $676.08 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $407.38 / $6,165.95
| Professional | | $239.88 | $407.38 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $18,197.01
| Facility | | $5,011.87 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $4,365.16 / $10,471.29
| Professional | | $281.84 | $4,365.16 | $10,471.29 |