- 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
- $412.83 / $789.57 / $1,029.89
| Professional | | $412.83 | $789.57 | $1,029.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $659.68 / $1,118.17 / $5,321.00
| Facility | | $659.68 | $1,118.17 | $5,321.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $917.75 / $1,278.00 / $2,197.38
| Facility | | $917.75 | $1,278.00 | $2,197.38 |
- 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 |