- 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
- $507.86 / $781.61 / $1,436.67
| Professional | | $507.86 | $781.61 | $1,436.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.07 / $1,327.97 / $6,034.22
| Facility | | $682.07 | $1,327.97 | $6,034.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $953.00 / $1,391.95 / $2,256.42
| Facility | | $953.00 | $1,391.95 | $2,256.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $4,663.00 / $7,305.00
| Facility | | $3,044.00 | $4,663.00 | $7,305.00 |