- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.77 / $622.70 / $1,087.39
| Professional | | $303.77 | $622.70 | $1,087.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $593.17 / $1,008.25 / $7,273.98
| Facility | | $593.17 | $1,008.25 | $7,273.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.00 / $1,017.84 / $2,571.84
| Facility | | $691.00 | $1,017.84 | $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 |