- 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
- $221.87 / $1,198.26 / $1,687.30
| Professional | | $221.87 | $1,198.26 | $1,687.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.22 / $1,651.79 / $3,254.94
| Facility | | $436.22 | $1,651.79 | $3,254.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $565.12 / $1,622.05 / $2,617.06
| Facility | | $565.12 | $1,622.05 | $2,617.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,444.39 / $4,645.00 / $7,305.00
| Facility | | $2,444.39 | $4,645.00 | $7,305.00 |