- 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
- $450.38 / $640.36 / $1,511.92
| Professional | | $450.38 | $640.36 | $1,511.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.80 / $1,749.02 / $6,945.09
| Facility | | $758.80 | $1,749.02 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $953.00 / $1,526.72 / $2,428.62
| Facility | | $953.00 | $1,526.72 | $2,428.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,711.00 / $5,854.53 / $7,407.10
| Facility | | $3,711.00 | $5,854.53 | $7,407.10 |