- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.58 / $879.87 / $1,855.09
| Professional | | $566.58 | $879.87 | $1,855.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $879.02 / $1,498.92 / $7,123.00
| Facility | | $879.02 | $1,498.92 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.86 / $1,522.00 / $2,961.89
| Facility | | $1,107.86 | $1,522.00 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,180.89 / $6,006.07 / $8,514.60
| Facility | | $4,180.89 | $6,006.07 | $8,514.60 |