- 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
- $489.26 / $813.08 / $1,725.93
| Professional | | $489.26 | $813.08 | $1,725.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.34 / $1,240.16 / $3,396.00
| Facility | | $784.34 | $1,240.16 | $3,396.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.26 / $1,240.16 / $1,597.29
| Facility | | $1,023.26 | $1,240.16 | $1,597.29 |
- 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 |