- 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
- $435.73 / $678.39 / $1,138.97
| Professional | | $435.73 | $678.39 | $1,138.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $720.47 / $1,221.47 / $8,723.79
| Facility | | $720.47 | $1,221.47 | $8,723.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $723.00 / $1,323.88 / $2,865.45
| Facility | | $723.00 | $1,323.88 | $2,865.45 |
- 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 |