- 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
- $456.51 / $705.02 / $1,413.49
| Professional | | $456.51 | $705.02 | $1,413.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $607.78 / $1,202.39 / $7,123.00
| Facility | | $607.78 | $1,202.39 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $920.06 / $1,301.44 / $2,961.89
| Facility | | $920.06 | $1,301.44 | $2,961.89 |
- 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 |