- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,977.00 / $4,235.59 / $7,119.04
| Facility | | $2,977.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.64 / $1,081.08 / $1,391.56
| Professional | | $178.64 | $1,081.08 | $1,391.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.77 / $1,350.88 / $3,115.89
| Facility | | $358.77 | $1,350.88 | $3,115.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $416.30 / $1,620.25 / $2,424.52
| Facility | | $416.30 | $1,620.25 | $2,424.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $4,663.00 / $7,305.00
| Facility | | $1,770.00 | $4,663.00 | $7,305.00 |