- 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
- $649.42 / $904.98 / $1,953.38
| Professional | | $649.42 | $904.98 | $1,953.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,101.86 / $1,953.11 / $6,945.09
| Facility | | $1,101.86 | $1,953.11 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.30 / $1,821.47 / $2,428.62
| Facility | | $1,088.30 | $1,821.47 | $2,428.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |