- 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
- $885.19 / $1,413.71 / $2,567.46
| Professional | | $885.19 | $1,413.71 | $2,567.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,305.58 / $2,121.53 / $3,825.00
| Facility | | $1,305.58 | $2,121.53 | $3,825.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.77 / $2,121.53 / $2,834.84
| Facility | | $1,743.77 | $2,121.53 | $2,834.84 |
- 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 |