- 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
- $297.55 / $611.33 / $1,213.79
| Professional | | $297.55 | $611.33 | $1,213.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.71 / $785.55 / $5,567.24
| Facility | | $472.71 | $785.55 | $5,567.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $657.20 / $1,009.46 / $2,932.27
| Facility | | $657.20 | $1,009.46 | $2,932.27 |
- 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 |