- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $411.81 / $692.33 / $2,143.73
| Facility | | $411.81 | $692.33 | $2,143.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.98 / $1,666.91 / $2,626.51
| Professional | | $478.98 | $1,666.91 | $2,626.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.92 / $458.71 / $1,346.15
| Professional | | $311.92 | $458.71 | $1,346.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,986.00 / $8,986.00 / $8,986.00
| Facility | | $8,986.00 | $8,986.00 | $8,986.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.83 / $1,916.92 / $2,342.29
| Professional | | $1,123.83 | $1,916.92 | $2,342.29 |