- 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
- $358.12 / $5,616.18 / $7,784.23
| Professional | | $358.12 | $5,616.18 | $7,784.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $709.82 / $8,378.49 / $17,384.84
| Facility | | $709.82 | $8,378.49 | $17,384.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.62 / $9,128.52 / $13,885.85
| Facility | | $741.62 | $9,128.52 | $13,885.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |