- 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
- $617.52 / $1,017.56 / $1,707.42
| Professional | | $617.52 | $1,017.56 | $1,707.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $890.28 / $1,803.89 / $14,525.55
| Facility | | $890.28 | $1,803.89 | $14,525.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.00 / $1,958.91 / $5,275.65
| Facility | | $1,074.00 | $1,958.91 | $5,275.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |