- 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
- $595.54 / $1,088.19 / $2,049.87
| Professional | | $595.54 | $1,088.19 | $2,049.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $865.51 / $1,630.84 / $5,564.59
| Facility | | $865.51 | $1,630.84 | $5,564.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,389.35 / $1,708.88 / $2,510.01
| Facility | | $1,389.35 | $1,708.88 | $2,510.01 |
- 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 |