- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.35 / $8,018.32 / $9,260.41
| Facility | | $376.35 | $8,018.32 | $9,260.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.68 / $339.32 / $362.77
| Professional | | $326.68 | $339.32 | $362.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.11 / $469.11 / $557.17
| Professional | | $341.11 | $469.11 | $557.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,132.00 / $6,132.00 / $11,753.23
| Facility | | $6,132.00 | $6,132.00 | $11,753.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.77 / $441.00 / $845.24
| Professional | | $340.77 | $441.00 | $845.24 |