- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.94 / $2,239.38 / $6,298.62
| Facility | | $762.94 | $2,239.38 | $6,298.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.37 / $435.33 / $1,431.01
| Professional | | $278.37 | $435.33 | $1,431.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $480.93 / $970.40 / $7,561.00
| Facility | | $480.93 | $970.40 | $7,561.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.30 / $797.10 / $1,067.13
| Facility | | $533.30 | $797.10 | $1,067.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,341.00 / $1,775.00 / $28,134.95
| Facility | | $1,341.00 | $1,775.00 | $28,134.95 |