- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.15 / $684.15 / $4,749.31
| Professional | | $684.15 | $684.15 | $4,749.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,512.20 / $9,458.00 / $17,400.00
| Facility | | $8,512.20 | $9,458.00 | $17,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.87 / $938.14 / $4,683.08
| Professional | | $485.87 | $938.14 | $4,683.08 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $728.80 / $1,407.22 / $7,024.62
| Professional | 50 | $728.80 | $1,407.22 | $7,024.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,739.16 / $5,119.39 / $11,057.38
| Professional | | $3,739.16 | $5,119.39 | $11,057.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.97 / $2,352.48 / $3,704.74
| Professional | | $341.97 | $2,352.48 | $3,704.74 |