- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $3,162.28 / $8,912.51
| Professional | | $537.03 | $3,162.28 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $269.15 / $309.03
| Facility | | $158.49 | $269.15 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $181.97 / $269.15
| Professional | | $141.25 | $181.97 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $2,344.23 / $3,890.45
| Facility | | $275.42 | $2,344.23 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Professional | | $1,479.11 | $1,479.11 | $1,479.11 |