- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.98 / $4,736.00 / $13,898.42
| Facility | | $289.98 | $4,736.00 | $13,898.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.20 / $289.98 / $295.97
| Professional | | $285.20 | $289.98 | $295.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.12 / $357.94 / $502.25
| Professional | | $259.12 | $357.94 | $502.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.46 / $6,136.19 / $17,160.53
| Facility | | $1,787.46 | $6,136.19 | $17,160.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.14 / $406.42 / $656.04
| Professional | | $288.14 | $406.42 | $656.04 |