- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $4,677.35 / $8,128.31
| Professional | | $371.54 | $4,677.35 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,454.71 / $2,884.03
| Facility | | $602.56 | $2,454.71 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $954.99 / $1,698.24
| Facility | | $346.74 | $954.99 | $1,698.24 |