- 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
- $759.05 / $1,023.28 / $2,249.39
| Professional | | $759.05 | $1,023.28 | $2,249.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.70 / $2,279.96 / $6,945.09
| Facility | | $1,005.70 | $2,279.96 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.98 / $1,961.12 / $2,485.77
| Facility | | $1,294.98 | $1,961.12 | $2,485.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,711.00 / $5,854.53 / $7,407.10
| Facility | | $3,711.00 | $5,854.53 | $7,407.10 |