- 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
- $133.38 / $228.88 / $454.97
| Professional | | $133.38 | $228.88 | $454.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.60 / $305.83 / $1,607.00
| Facility | | $170.60 | $305.83 | $1,607.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.00 / $329.65 / $453.65
| Facility | | $276.00 | $329.65 | $453.65 |
- 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 |