- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.28 / $630.57 / $1,270.33
| Professional | | $407.28 | $630.57 | $1,270.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.98 / $1,073.59 / $4,645.00
| Facility | | $510.98 | $1,073.59 | $4,645.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $832.20 / $1,107.43 / $1,597.11
| Facility | | $832.20 | $1,107.43 | $1,597.11 |
- 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 |