- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.78 / $594.80 / $1,338.68
| Professional | | $380.78 | $594.80 | $1,338.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.50 / $1,011.07 / $6,608.00
| Facility | | $533.50 | $1,011.07 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $693.00 / $1,046.07 / $2,256.42
| Facility | | $693.00 | $1,046.07 | $2,256.42 |
- 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 |