- 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
- $450.27 / $703.48 / $1,639.60
| Professional | | $450.27 | $703.48 | $1,639.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.28 / $1,180.20 / $5,301.00
| Facility | | $710.28 | $1,180.20 | $5,301.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.74 / $1,235.76 / $1,750.65
| Facility | | $933.74 | $1,235.76 | $1,750.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |