- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.88 / $3,489.13 / $7,119.04
| Facility | | $926.88 | $3,489.13 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.33 / $436.05 / $1,579.45
| Professional | | $289.33 | $436.05 | $1,579.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $322.70 / $740.34 / $27,092.38
| Facility | | $322.70 | $740.34 | $27,092.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.04 / $849.32 / $27,092.38
| Facility | | $478.04 | $849.32 | $27,092.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $11,869.99
| Facility | | $7,221.00 | $8,060.00 | $11,869.99 |