- 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
- $545.70 / $831.67 / $2,056.80
| Professional | | $545.70 | $831.67 | $2,056.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $692.47 / $1,270.68 / $1,640.00
| Facility | | $692.47 | $1,270.68 | $1,640.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.26 / $1,291.83 / $1,678.64
| Facility | | $1,012.26 | $1,291.83 | $1,678.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,640.00 / $2,126.00
| Facility | | $1,204.00 | $1,640.00 | $2,126.00 |