- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,148.15
| Professional | | $912.01 | $912.01 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $56.23 / $3,235.94
| Facility | | $54.95 | $56.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $691.83 / $1,047.13
| Facility | | $478.63 | $691.83 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.94 / $1,000.00 / $1,202.26
| Professional | | $7.94 | $1,000.00 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $691.83 / $1,047.13
| Facility | | $478.63 | $691.83 | $1,047.13 |