- 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
- $223.66 / $365.66 / $1,113.58
| Professional | | $223.66 | $365.66 | $1,113.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.39 / $542.82 / $4,271.64
| Facility | | $317.39 | $542.82 | $4,271.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $408.31 / $529.11 / $688.61
| Facility | | $408.31 | $529.11 | $688.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $4,663.00 / $7,305.00
| Facility | | $3,044.00 | $4,663.00 | $7,305.00 |