- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,367.46 / $4,760.00 / $7,120.36
| Facility | | $1,367.46 | $4,760.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.33 / $697.50 / $1,733.97
| Professional | | $457.33 | $697.50 | $1,733.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.50 / $15,061.00 / $48,977.74
| Facility | | $707.50 | $15,061.00 | $48,977.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $873.93 / $1,805.98 / $27,232.66
| Facility | | $873.93 | $1,805.98 | $27,232.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,855.00 / $16,742.00 / $21,923.00
| Facility | | $12,855.00 | $16,742.00 | $21,923.00 |