- 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
- $457.43 / $726.14 / $1,987.50
| Professional | | $457.43 | $726.14 | $1,987.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $780.85 / $1,220.59 / $6,267.00
| Facility | | $780.85 | $1,220.59 | $6,267.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $915.26 / $1,300.54 / $2,961.89
| Facility | | $915.26 | $1,300.54 | $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 |