- 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
- $218.05 / $1,114.01 / $2,423.92
| Professional | | $218.05 | $1,114.01 | $2,423.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.19 / $1,501.17 / $6,055.31
| Facility | | $327.19 | $1,501.17 | $6,055.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $471.36 / $2,034.74 / $3,162.53
| Facility | | $471.36 | $2,034.74 | $3,162.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $6,588.00 / $10,320.00
| Facility | | $1,770.00 | $6,588.00 | $10,320.00 |