- 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
- $528.91 / $841.10 / $2,089.46
| Professional | | $528.91 | $841.10 | $2,089.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $901.34 / $1,426.96 / $7,896.02
| Facility | | $901.34 | $1,426.96 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.30 / $1,507.87 / $2,961.89
| Facility | | $1,053.30 | $1,507.87 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |