- 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
- $258.58 / $604.50 / $978.73
| Professional | | $258.58 | $604.50 | $978.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $635.59 / $1,054.47 / $14,396.24
| Facility | | $635.59 | $1,054.47 | $14,396.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $1,183.02 / $5,383.60
| Facility | | $680.00 | $1,183.02 | $5,383.60 |
- 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 |