- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.85 / $3,978.38 / $8,803.02
| Facility | | $258.85 | $3,978.38 | $8,803.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.46 / $316.83 / $331.93
| Professional | | $241.46 | $316.83 | $331.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.46 / $342.66 / $476.82
| Professional | | $227.46 | $342.66 | $476.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,132.00 / $9,861.77 / $32,447.86
| Facility | | $6,132.00 | $9,861.77 | $32,447.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.86 / $375.11 / $767.19
| Professional | | $289.86 | $375.11 | $767.19 |