- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $4,073.80 / $7,762.47
| Facility | | $389.05 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $380.19 / $398.11
| Professional | | $338.84 | $380.19 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $15,488.17 / $26,915.35
| Facility | | $3,311.31 | $15,488.17 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $501.19 / $1,000.00
| Professional | | $331.13 | $501.19 | $1,000.00 |