- 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
- $510.55 / $780.44 / $1,514.79
| Professional | | $510.55 | $780.44 | $1,514.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $514.35 / $1,287.90 / $7,123.00
| Facility | | $514.35 | $1,287.90 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $827.48 / $1,363.36 / $2,961.89
| Facility | | $827.48 | $1,363.36 | $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 |