- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.98 / $4,760.00 / $9,185.68
| Facility | | $1,737.98 | $4,760.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.50 / $818.73 / $1,776.84
| Professional | | $535.50 | $818.73 | $1,776.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $622.41 / $1,408.01 / $8,957.00
| Facility | | $622.41 | $1,408.01 | $8,957.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $999.65 / $1,475.24 / $2,961.89
| Facility | | $999.65 | $1,475.24 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |