- 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
- $562.73 / $888.21 / $1,978.23
| Professional | | $562.73 | $888.21 | $1,978.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $916.16 / $1,458.66 / $6,267.00
| Facility | | $916.16 | $1,458.66 | $6,267.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.00 / $1,556.87 / $2,961.89
| Facility | | $1,057.00 | $1,556.87 | $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 |