- 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
- $360.09 / $663.89 / $1,135.86
| Professional | | $360.09 | $663.89 | $1,135.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $623.53 / $1,168.68 / $8,328.70
| Facility | | $623.53 | $1,168.68 | $8,328.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.00 / $1,317.33 / $2,571.84
| Facility | | $719.00 | $1,317.33 | $2,571.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |