- 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
- $586.78 / $829.44 / $1,469.86
| Professional | | $586.78 | $829.44 | $1,469.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $925.45 / $1,837.79 / $7,104.12
| Facility | | $925.45 | $1,837.79 | $7,104.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.76 / $1,614.54 / $2,052.00
| Facility | | $1,008.76 | $1,614.54 | $2,052.00 |
- 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 |