- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.16 / $921.83 / $1,512.19
| Professional | | $683.16 | $921.83 | $1,512.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.78 / $2,094.53 / $9,874.90
| Facility | | $930.78 | $2,094.53 | $9,874.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.00 / $2,026.52 / $3,123.31
| Facility | | $1,023.00 | $2,026.52 | $3,123.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,859.18 / $7,091.00 / $10,320.00
| Facility | | $4,859.18 | $7,091.00 | $10,320.00 |