- 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
- $58.28 / $543.62 / $1,719.94
| Professional | | $58.28 | $543.62 | $1,719.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.10 / $1,018.19 / $1,781.84
| Facility | | $136.10 | $1,018.19 | $1,781.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.44 / $1,018.19 / $1,583.86
| Facility | | $153.44 | $1,018.19 | $1,583.86 |
- 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 |