- 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
- $362.55 / $706.85 / $1,362.84
| Professional | | $362.55 | $706.85 | $1,362.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.07 / $1,150.25 / $8,722.70
| Facility | | $850.07 | $1,150.25 | $8,722.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.07 / $1,179.31 / $4,818.76
| Facility | | $850.07 | $1,179.31 | $4,818.76 |
- 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 |