- 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
- $589.91 / $938.90 / $2,044.44
| Professional | | $589.91 | $938.90 | $2,044.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.64 / $1,515.27 / $4,645.00
| Facility | | $875.64 | $1,515.27 | $4,645.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,143.00 / $1,425.02 / $1,857.73
| Facility | | $1,143.00 | $1,425.02 | $1,857.73 |
- 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 |