- 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
- $230.89 / $1,406.23 / $2,463.09
| Professional | | $230.89 | $1,406.23 | $2,463.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $611.70 / $2,304.46 / $5,467.65
| Facility | | $611.70 | $2,304.46 | $5,467.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $611.70 / $1,759.36 / $2,800.41
| Facility | | $611.70 | $1,759.36 | $2,800.41 |
- 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 |