- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.33 / $2,173.60 / $9,534.00
| Facility | | $477.33 | $2,173.60 | $9,534.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $444.81 / $6,277.99
| Professional | | $318.22 | $444.81 | $6,277.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $337.31 / $1,270.80
| Facility | | $318.22 | $337.31 | $1,270.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $3,500.00
| Professional | | $30.00 | $30.00 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,303.34 / $2,303.34 / $2,775.91
| Facility | | $2,303.34 | $2,303.34 | $2,775.91 |