- 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
- $568.30 / $982.81 / $1,647.01
| Professional | | $568.30 | $982.81 | $1,647.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.26 / $1,630.95 / $20,740.72
| Facility | | $854.26 | $1,630.95 | $20,740.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.00 / $1,873.96 / $8,863.74
| Facility | | $1,044.00 | $1,873.96 | $8,863.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $7,091.00 / $10,320.00
| Facility | | $5,341.00 | $7,091.00 | $10,320.00 |