- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $3,666.78 / $7,119.04
| Facility | | $2,906.00 | $3,666.78 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.22 / $1,413.03 / $1,774.83
| Professional | | $315.22 | $1,413.03 | $1,774.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $543.66 / $2,364.62 / $8,342.00
| Facility | | $543.66 | $2,364.62 | $8,342.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $610.05 / $2,482.96 / $3,170.91
| Facility | | $610.05 | $2,482.96 | $3,170.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |