- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.94 / $661.83 / $1,058.50
| Professional | | $348.94 | $661.83 | $1,058.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.05 / $953.70 / $4,033.83
| Facility | | $593.05 | $953.70 | $4,033.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $806.73 / $1,038.36 / $1,331.66
| Facility | | $806.73 | $1,038.36 | $1,331.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |