- 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
- $148.09 / $251.21 / $444.65
| Professional | | $148.09 | $251.21 | $444.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.86 / $380.01 / $1,914.00
| Facility | | $267.86 | $380.01 | $1,914.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.00 / $361.59 / $497.43
| Facility | | $240.00 | $361.59 | $497.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,607.00 / $2,126.00
| Facility | | $1,204.00 | $1,607.00 | $2,126.00 |