- 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
- $658.30 / $1,157.18 / $2,219.13
| Professional | | $658.30 | $1,157.18 | $2,219.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $953.00 / $1,801.15 / $5,023.00
| Facility | | $953.00 | $1,801.15 | $5,023.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.00 / $1,716.91 / $2,242.25
| Facility | | $1,460.00 | $1,716.91 | $2,242.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $5,023.00 / $7,305.00
| Facility | | $3,044.00 | $5,023.00 | $7,305.00 |