- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.10 / $6,907.00 / $15,945.44
| Facility | | $390.10 | $6,907.00 | $15,945.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.49 / $394.40 / $516.25
| Professional | | $387.49 | $394.40 | $516.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.40 / $532.76 / $683.11
| Professional | | $351.40 | $532.76 | $683.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,418.31 / $5,418.31 / $7,150.79
| Facility | | $5,418.31 | $5,418.31 | $7,150.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.22 / $575.55 / $892.78
| Professional | | $400.22 | $575.55 | $892.78 |