- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.20 / $3,925.00 / $9,633.37
| Facility | | $280.20 | $3,925.00 | $9,633.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.34 / $259.17 / $385.85
| Professional | | $218.34 | $259.17 | $385.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.97 / $318.87 / $413.31
| Professional | | $231.97 | $318.87 | $413.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,986.82 / $5,193.64 / $11,864.41
| Facility | | $1,986.82 | $5,193.64 | $11,864.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.56 / $330.97 / $653.33
| Professional | | $252.56 | $330.97 | $653.33 |