- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $921.09 / $3,837.88 / $18,421.84
| Facility | | $921.09 | $3,837.88 | $18,421.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.75 / $921.09 / $119,998.80
| Professional | | $818.75 | $921.09 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.36 / $818.75 / $2,046.71
| Facility | | $554.36 | $818.75 | $2,046.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,288.64 / $3,288.64 / $3,288.64
| Professional | | $3,288.64 | $3,288.64 | $3,288.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $341.15 / $989.32
| Professional | | $286.56 | $341.15 | $989.32 |