- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.09 / $184.48 / $420.92
| Professional | | $74.09 | $184.48 | $420.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.49 / $211.40 / $1,607.00
| Facility | | $113.49 | $211.40 | $1,607.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.90 / $302.04 / $439.03
| Facility | | $168.90 | $302.04 | $439.03 |
- 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 |