- 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
- $377.45 / $565.40 / $1,329.41
| Professional | | $377.45 | $565.40 | $1,329.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $633.72 / $1,062.88 / $4,873.45
| Facility | | $633.72 | $1,062.88 | $4,873.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $822.00 / $1,062.88 / $1,597.11
| Facility | | $822.00 | $1,062.88 | $1,597.11 |
- 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 |