- 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
- $637.78 / $1,053.92 / $1,846.00
| Professional | | $637.78 | $1,053.92 | $1,846.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $989.33 / $1,831.51 / $12,371.41
| Facility | | $989.33 | $1,831.51 | $12,371.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,177.00 / $2,106.09 / $4,818.76
| Facility | | $1,177.00 | $2,106.09 | $4,818.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |