- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,778.89 / $7,119.04
| Facility | | $2,906.00 | $4,778.89 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.37 / $1,413.68 / $1,874.44
| Professional | | $237.37 | $1,413.68 | $1,874.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $481.29 / $1,682.96 / $3,521.67
| Facility | | $481.29 | $1,682.96 | $3,521.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.40 / $1,522.92 / $3,280.69
| Facility | | $604.40 | $1,522.92 | $3,280.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $4,663.00 / $7,305.00
| Facility | | $1,770.00 | $4,663.00 | $7,305.00 |