- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $4,786.30 / $28,840.32
| Facility | | $245.47 | $4,786.30 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $776.25 / $10,964.78
| Professional | | $676.08 | $776.25 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,128.31 / $23,988.33
| Facility | | $4,466.84 | $8,128.31 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41,686.94 / $41,686.94 / $41,686.94
| Professional | | $41,686.94 | $41,686.94 | $41,686.94 |