- 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
- $153.47 / $439.37 / $910.36
| Professional | | $153.47 | $439.37 | $910.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $279.89 / $641.73 / $3,825.00
| Facility | | $279.89 | $641.73 | $3,825.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.50 / $715.78 / $1,622.05
| Facility | | $351.50 | $715.78 | $1,622.05 |
- 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 |