- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.15 / $3,140.00 / $7,103.06
| Facility | | $165.15 | $3,140.00 | $7,103.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.66 / $2,750.24 / $3,699.28
| Professional | | $146.66 | $2,750.24 | $3,699.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.56 / $305.57 / $5,439.75
| Professional | | $186.56 | $305.57 | $5,439.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.93 / $2,318.48 / $23,971.44
| Facility | | $1,342.93 | $2,318.48 | $23,971.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,047.06 / $4,806.47 / $6,937.67
| Professional | | $3,047.06 | $4,806.47 | $6,937.67 |