- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.46 / $910.31 / $1,759.75
| Professional | | $575.46 | $910.31 | $1,759.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $910.54 / $1,488.59 / $6,267.00
| Facility | | $910.54 | $1,488.59 | $6,267.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,050.00 / $1,590.01 / $2,961.89
| Facility | | $1,050.00 | $1,590.01 | $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 |