- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.88 / $572.25 / $1,085.01
| Professional | | $298.88 | $572.25 | $1,085.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $614.00 / $872.47 / $8,586.74
| Facility | | $614.00 | $872.47 | $8,586.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $614.00 / $966.39 / $3,170.91
| Facility | | $614.00 | $966.39 | $3,170.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,711.00 / $6,110.41 / $8,342.00
| Facility | | $3,711.00 | $6,110.41 | $8,342.00 |