- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $3,801.89 / $6,760.83
| Facility | | $281.84 | $3,801.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $1,000.00 / $1,318.26
| Professional | | $181.97 | $1,000.00 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $1,584.89 / $16,982.44
| Facility | | $426.58 | $1,584.89 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,023.29 / $1,905.46
| Professional | | $371.54 | $1,023.29 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,332.54 / $18,620.87
| Facility | | $5,495.41 | $9,332.54 | $18,620.87 |