- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $365.85 / $849.06 / $3,948.46
| Facility | | $365.85 | $849.06 | $3,948.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.85 / $517.72 / $586.75
| Professional | | $365.85 | $517.72 | $586.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $674.76 / $1,521.43 / $3,163.15
| Facility | | $674.76 | $1,521.43 | $3,163.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.80 / $904.28 / $1,257.71
| Professional | | $724.80 | $904.28 | $1,257.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $8,702.00 / $8,702.00
| Facility | | $8,702.00 | $8,702.00 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.92 / $414.17 / $707.55
| Professional | | $289.92 | $414.17 | $707.55 |