- 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
- $183.75 / $570.45 / $1,161.45
| Professional | | $183.75 | $570.45 | $1,161.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $488.69 / $1,152.68 / $8,545.00
| Facility | | $488.69 | $1,152.68 | $8,545.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $467.30 / $1,169.76 / $3,869.05
| Facility | | $467.30 | $1,169.76 | $3,869.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $7,091.00 / $10,320.00
| Facility | | $5,341.00 | $7,091.00 | $10,320.00 |