- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.15 / $420.60 / $10,308.15
| Professional | | $332.15 | $420.60 | $10,308.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $245.34
| Facility | | $55.00 | $55.00 | $245.34 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.65 / $1,506.10 / $3,597.64
| Facility | | $100.65 | $1,506.10 | $3,597.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,246.39 / $4,642.00 / $6,214.50
| Professional | | $4,246.39 | $4,642.00 | $6,214.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.41 / $1,506.10 / $3,597.64
| Facility | | $101.41 | $1,506.10 | $3,597.64 |