- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.53 / $9,727.40 / $16,467.00
| Facility | | $159.53 | $9,727.40 | $16,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.53 / $159.53 / $175.03
| Professional | | $159.53 | $159.53 | $175.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.16 / $2,216.51 / $3,868.86
| Facility | | $1,057.16 | $2,216.51 | $3,868.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $184.84 / $324.08
| Professional | | $155.00 | $184.84 | $324.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.51 / $175.48 / $286.67
| Facility | | $146.51 | $175.48 | $286.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Professional | | $55.00 | $55.00 | $55.00 |