- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $526.25 / $6,197.80 / $69,571.27
| Facility | | $526.25 | $6,197.80 | $69,571.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.36 / $526.25 / $1,064.24
| Professional | | $163.36 | $526.25 | $1,064.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.67 / $530.30 / $1,196.40
| Professional | | $177.67 | $530.30 | $1,196.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,153.63 / $3,153.63 / $3,153.63
| Facility | | $3,153.63 | $3,153.63 | $3,153.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.54 / $299.54 / $299.54
| Professional | | $299.54 | $299.54 | $299.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.05 / $1,015.49 / $2,243.03
| Professional | | $851.05 | $1,015.49 | $2,243.03 |