- 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
- $634.59 / $1,238.84 / $2,707.46
| Professional | | $634.59 | $1,238.84 | $2,707.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $967.95 / $1,701.98 / $7,091.00
| Facility | | $967.95 | $1,701.98 | $7,091.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.23 / $2,216.54 / $2,961.89
| Facility | | $1,261.23 | $2,216.54 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |