- 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
- $498.70 / $791.51 / $1,685.91
| Professional | | $498.70 | $791.51 | $1,685.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $703.44 / $1,301.78 / $7,123.00
| Facility | | $703.44 | $1,301.78 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $946.00 / $1,332.64 / $2,961.89
| Facility | | $946.00 | $1,332.64 | $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 |