- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,021.14 / $4,078.00 / $7,119.04
| Facility | | $2,021.14 | $4,078.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.55 / $952.76 / $2,269.65
| Professional | | $621.55 | $952.76 | $2,269.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.56 / $1,649.77 / $6,608.00
| Facility | | $808.56 | $1,649.77 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.97 / $1,793.27 / $2,256.42
| Facility | | $1,232.97 | $1,793.27 | $2,256.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |