- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.58 / $1,099.25 / $17,419.93
| Professional | | $451.58 | $1,099.25 | $17,419.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $7,589.59
| Facility | | $55.00 | $55.00 | $7,589.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.55 / $17,449.43 / $17,449.43
| Professional | | $1,187.55 | $17,449.43 | $17,449.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.62 / $364.13 / $5,966.97
| Facility | | $293.62 | $364.13 | $5,966.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.80 / $326.80 / $326.80
| Professional | | $326.80 | $326.80 | $326.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.62 / $364.13 / $5,966.97
| Facility | | $293.62 | $364.13 | $5,966.97 |