- 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
- $592.11 / $935.09 / $2,111.96
| Professional | | $592.11 | $935.09 | $2,111.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $997.20 / $1,559.10 / $6,267.00
| Facility | | $997.20 | $1,559.10 | $6,267.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.00 / $1,626.87 / $2,961.89
| Facility | | $1,141.00 | $1,626.87 | $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 |