- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,311.70 / $4,033.00 / $7,119.04
| Facility | | $1,311.70 | $4,033.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.55 / $801.85 / $1,405.15
| Professional | | $437.55 | $801.85 | $1,405.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $690.37 / $1,166.73 / $8,342.00
| Facility | | $690.37 | $1,166.73 | $8,342.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.06 / $1,314.41 / $8,516.84
| Facility | | $957.06 | $1,314.41 | $8,516.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |