- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,139.19 / $3,701.00 / $7,119.04
| Facility | | $1,139.19 | $3,701.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.11 / $586.07 / $1,198.06
| Professional | | $380.11 | $586.07 | $1,198.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $494.21 / $1,001.97 / $6,608.00
| Facility | | $494.21 | $1,001.97 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.60 / $1,093.21 / $2,256.42
| Facility | | $748.60 | $1,093.21 | $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 |