- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $4,786.30 / $7,413.10
| Facility | | $302.00 | $4,786.30 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $263.03 / $676.08
| Professional | | $151.36 | $263.03 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $9,332.54 / $21,877.62
| Facility | | $346.74 | $9,332.54 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $416.87 / $616.60
| Professional | | $346.74 | $416.87 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $12,022.64 / $21,877.62
| Facility | | $8,511.38 | $12,022.64 | $21,877.62 |