- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $6,165.95 / $16,218.10
| Facility | | $891.25 | $6,165.95 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $724.44 / $3,311.31
| Professional | | $302.00 | $724.44 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $912.01 / $2,041.74
| Professional | | $331.13 | $912.01 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $1,479.11 / $2,137.96
| Professional | | $309.03 | $1,479.11 | $2,137.96 |