- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,042.03
| Facility | | $3,468.00 | $4,917.20 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.33 / $549.72 / $1,077.94
| Professional | | $306.33 | $549.72 | $1,077.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $686.00 / $1,130.54 / $26,876.61
| Facility | | $686.00 | $1,130.54 | $26,876.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $686.00 / $1,039.70 / $15,091.68
| Facility | | $686.00 | $1,039.70 | $15,091.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,398.00 / $15,622.00 / $26,415.00
| Facility | | $10,398.00 | $15,622.00 | $26,415.00 |