- 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
- $297.67 / $815.41 / $2,662.87
| Professional | | $297.67 | $815.41 | $2,662.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $693.66 / $1,491.84 / $4,713.89
| Facility | | $693.66 | $1,491.84 | $4,713.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $789.14 / $2,951.38 / $4,824.33
| Facility | | $789.14 | $2,951.38 | $4,824.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,607.00 / $2,126.00
| Facility | | $1,204.00 | $1,607.00 | $2,126.00 |