- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,693.00 / $5,549.00 / $7,943.37
| Facility | | $4,693.00 | $5,549.00 | $7,943.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.19 / $594.55 / $2,920.87
| Professional | | $410.19 | $594.55 | $2,920.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $548.47 / $1,023.32 / $23,817.66
| Facility | | $548.47 | $1,023.32 | $23,817.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.65 / $1,316.74 / $19,048.02
| Facility | | $728.65 | $1,316.74 | $19,048.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,234.00 / $9,673.00 / $14,242.22
| Facility | | $7,234.00 | $9,673.00 | $14,242.22 |