- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,545.00 / $5,463.36 / $13,841.56
| Facility | | $1,545.00 | $5,463.36 | $13,841.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.81 / $124.81 / $2,707.20
| Professional | | $124.81 | $124.81 | $2,707.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,350.61 / $4,406.97 / $8,524.51
| Facility | | $3,350.61 | $4,406.97 | $8,524.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.62 / $1,242.00 / $4,406.00
| Facility | | $298.62 | $1,242.00 | $4,406.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.62 / $407.62 / $4,317.00
| Facility | | $298.62 | $407.62 | $4,317.00 |