- 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
- $260.13 / $468.72 / $1,163.84
| Professional | | $260.13 | $468.72 | $1,163.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $619.36 / $1,059.38 / $6,306.00
| Facility | | $619.36 | $1,059.38 | $6,306.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.54 / $1,059.38 / $1,908.09
| Facility | | $676.54 | $1,059.38 | $1,908.09 |
- 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 |