- 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
- $341.88 / $696.46 / $1,806.60
| Professional | | $341.88 | $696.46 | $1,806.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $552.59 / $1,024.04 / $5,567.24
| Facility | | $552.59 | $1,024.04 | $5,567.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $754.72 / $1,141.92 / $3,529.19
| Facility | | $754.72 | $1,141.92 | $3,529.19 |
- 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 |