- 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
- $593.54 / $937.67 / $1,946.45
| Professional | | $593.54 | $937.67 | $1,946.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.19 / $1,547.62 / $6,267.00
| Facility | | $961.19 | $1,547.62 | $6,267.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,118.00 / $1,632.01 / $2,961.89
| Facility | | $1,118.00 | $1,632.01 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $4,663.00 / $7,305.00
| Facility | | $3,044.00 | $4,663.00 | $7,305.00 |