- 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
- $477.38 / $747.24 / $1,896.13
| Professional | | $477.38 | $747.24 | $1,896.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $757.47 / $1,301.54 / $7,896.02
| Facility | | $757.47 | $1,301.54 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $953.00 / $1,357.06 / $2,961.89
| Facility | | $953.00 | $1,357.06 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |