- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.84 / $4,964.00 / $7,120.36
| Facility | | $808.84 | $4,964.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.65 / $729.06 / $1,142.06
| Professional | | $417.65 | $729.06 | $1,142.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.76 / $1,236.89 / $14,525.55
| Facility | | $773.76 | $1,236.89 | $14,525.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $717.00 / $1,324.18 / $5,275.65
| Facility | | $717.00 | $1,324.18 | $5,275.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |