- 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
- $418.11 / $662.43 / $1,460.50
| Professional | | $418.11 | $662.43 | $1,460.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $623.53 / $1,107.57 / $7,123.00
| Facility | | $623.53 | $1,107.57 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.17 / $1,186.22 / $2,961.89
| Facility | | $846.17 | $1,186.22 | $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 |