- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,833.00 / $3,666.78 / $7,119.04
| Facility | | $2,833.00 | $3,666.78 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.20 / $684.97 / $1,193.46
| Professional | | $376.20 | $684.97 | $1,193.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $825.00 / $1,108.51 / $12,656.46
| Facility | | $825.00 | $1,108.51 | $12,656.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.00 / $1,227.06 / $4,818.76
| Facility | | $752.00 | $1,227.06 | $4,818.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,523.00 / $11,869.99
| Facility | | $7,221.00 | $8,523.00 | $11,869.99 |