- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.29 / $818.54 / $1,560.77
| Professional | | $482.29 | $818.54 | $1,560.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $774.35 / $1,255.46 / $1,966.00
| Facility | | $774.35 | $1,255.46 | $1,966.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.21 / $1,256.89 / $1,597.29
| Facility | | $1,044.21 | $1,256.89 | $1,597.29 |
- 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 |