- 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
- $157.91 / $247.82 / $940.42
| Professional | | $157.91 | $247.82 | $940.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.37 / $368.15 / $1,775.00
| Facility | | $196.37 | $368.15 | $1,775.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.63 / $370.06 / $509.94
| Facility | | $293.63 | $370.06 | $509.94 |
- 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 |