- 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
- $410.40 / $652.70 / $1,170.45
| Professional | | $410.40 | $652.70 | $1,170.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $764.22 / $1,218.43 / $8,586.74
| Facility | | $764.22 | $1,218.43 | $8,586.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $736.00 / $1,350.46 / $3,170.91
| Facility | | $736.00 | $1,350.46 | $3,170.91 |
- 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 |