- 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
- $907.94 / $1,448.63 / $2,824.34
| Professional | | $907.94 | $1,448.63 | $2,824.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $2,089.30 / $2,658.99
| Facility | | $1,204.00 | $2,089.30 | $2,658.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,793.68 / $2,176.83 / $2,881.10
| Facility | | $1,793.68 | $2,176.83 | $2,881.10 |
- 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 |