- 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
- $903.83 / $1,460.89 / $2,674.10
| Professional | | $903.83 | $1,460.89 | $2,674.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.58 / $2,431.26 / $9,224.20
| Facility | | $1,278.58 | $2,431.26 | $9,224.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,824.11 / $2,593.88 / $7,094.08
| Facility | | $1,824.11 | $2,593.88 | $7,094.08 |
- 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 |