- 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
- $216.56 / $837.23 / $1,993.56
| Professional | | $216.56 | $837.23 | $1,993.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $361.69 / $1,168.43 / $2,338.00
| Facility | | $361.69 | $1,168.43 | $2,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $448.31 / $1,534.19 / $2,043.16
| Facility | | $448.31 | $1,534.19 | $2,043.16 |
- 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 |