- 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
- $314.24 / $625.21 / $1,171.08
| Professional | | $314.24 | $625.21 | $1,171.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $737.26 / $1,021.28 / $13,399.54
| Facility | | $737.26 | $1,021.28 | $13,399.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $737.26 / $1,028.25 / $8,863.74
| Facility | | $737.26 | $1,028.25 | $8,863.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $5,023.00 / $7,305.00
| Facility | | $3,044.00 | $5,023.00 | $7,305.00 |