- 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
- $429.67 / $643.04 / $2,021.27
| Professional | | $429.67 | $643.04 | $2,021.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.45 / $979.61 / $6,827.61
| Facility | | $540.45 | $979.61 | $6,827.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.54 / $1,394.29 / $2,630.67
| Facility | | $814.54 | $1,394.29 | $2,630.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $5,327.00 / $8,342.00
| Facility | | $1,770.00 | $5,327.00 | $8,342.00 |