- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,042.03
| Facility | | $3,468.00 | $4,917.20 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.52 / $247.76 / $588.04
| Professional | | $106.52 | $247.76 | $588.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.59 / $293.76 / $1,607.00
| Facility | | $163.59 | $293.76 | $1,607.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.91 / $345.19 / $589.22
| Facility | | $240.91 | $345.19 | $589.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,623.00 / $2,126.00
| Facility | | $1,204.00 | $1,623.00 | $2,126.00 |