- 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
- $404.00 / $680.46 / $1,190.55
| Professional | | $404.00 | $680.46 | $1,190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $646.04 / $1,051.06 / $1,966.00
| Facility | | $646.04 | $1,051.06 | $1,966.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $872.93 / $1,051.06 / $1,597.11
| Facility | | $872.93 | $1,051.06 | $1,597.11 |
- 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 |