- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.72 / $1,135.69 / $2,012.53
| Professional | | $236.72 | $1,135.69 | $2,012.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $408.29 / $1,611.00 / $4,985.21
| Facility | | $408.29 | $1,611.00 | $4,985.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.86 / $1,545.41 / $2,443.38
| Facility | | $458.86 | $1,545.41 | $2,443.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,775.00 / $3,522.00 / $5,454.00
| Facility | | $1,775.00 | $3,522.00 | $5,454.00 |