- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,671.00 / $3,617.00 / $6,329.00
| Facility | | $1,671.00 | $3,617.00 | $6,329.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.78 / $1,201.78 / $1,507.37
| Professional | | $1,201.78 | $1,201.78 | $1,507.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $448.92 / $1,704.86 / $2,700.74
| Facility | | $448.92 | $1,704.86 | $2,700.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.00 / $1,234.00 / $2,041.00
| Facility | | $803.00 | $1,234.00 | $2,041.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $683.00 / $1,409.00 / $2,175.00
| Facility | | $683.00 | $1,409.00 | $2,175.00 |