- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.09 / $5,408.10 / $8,819.06
| Facility | | $247.09 | $5,408.10 | $8,819.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.22 / $568.53 / $2,703.82
| Professional | | $221.22 | $568.53 | $2,703.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.24 / $614.05 / $2,936.43
| Professional | | $313.24 | $614.05 | $2,936.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,236.67 / $10,938.32 / $20,027.75
| Facility | | $5,236.67 | $10,938.32 | $20,027.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.22 / $2,505.87 / $4,427.06
| Professional | | $1,772.22 | $2,505.87 | $4,427.06 |