- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,778.89 / $7,119.04
| Facility | | $2,906.00 | $4,778.89 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.85 / $1,614.00 / $3,695.66
| Professional | | $410.85 | $1,614.00 | $3,695.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.52 / $2,164.51 / $6,350.97
| Facility | | $617.52 | $2,164.51 | $6,350.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $887.40 / $2,683.40 / $3,538.28
| Facility | | $887.40 | $2,683.40 | $3,538.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,484.10 / $7,091.00 / $10,606.69
| Facility | | $4,484.10 | $7,091.00 | $10,606.69 |