- 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
- $275.20 / $442.20 / $1,387.64
| Professional | | $275.20 | $442.20 | $1,387.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $414.66 / $779.42 / $13,476.00
| Facility | | $414.66 | $779.42 | $13,476.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $611.00 / $784.46 / $5,874.92
| Facility | | $611.00 | $784.46 | $5,874.92 |
- 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 |