- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.15 / $570.98 / $10,308.15
| Professional | | $332.15 | $570.98 | $10,308.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.97 / $2,033.23 / $3,722.44
| Facility | | $107.97 | $2,033.23 | $3,722.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.00 / $2,608.00 / $2,863.00
| Professional | | $2,608.00 | $2,608.00 | $2,863.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $223.55 / $9,980.60
| Facility | | $55.00 | $223.55 | $9,980.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,147.21 / $11,431.36 / $11,431.36
| Professional | | $3,147.21 | $11,431.36 | $11,431.36 |