- 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
- $516.37 / $710.19 / $1,508.17
| Professional | | $516.37 | $710.19 | $1,508.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $624.65 / $1,195.42 / $6,267.00
| Facility | | $624.65 | $1,195.42 | $6,267.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $934.91 / $1,289.11 / $2,961.89
| Facility | | $934.91 | $1,289.11 | $2,961.89 |
- 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 |