- 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
- $446.36 / $871.82 / $1,548.54
| Professional | | $446.36 | $871.82 | $1,548.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $857.69 / $1,393.72 / $7,273.98
| Facility | | $857.69 | $1,393.72 | $7,273.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.00 / $1,488.85 / $2,571.84
| Facility | | $975.00 | $1,488.85 | $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 |