- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.01 / $1,469.06 / $10,922.00
| Facility | | $260.01 | $1,469.06 | $10,922.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.01 / $260.01 / $411.25
| Professional | | $260.01 | $260.01 | $411.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,135.25 / $19,037.08 / $30,907.88
| Facility | | $10,135.25 | $19,037.08 | $30,907.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,585.30 / $18,585.30 / $40,301.98
| Facility | | $18,585.30 | $18,585.30 | $40,301.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.66 / $24.66 / $96.70
| Professional | | $24.66 | $24.66 | $96.70 |