- 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
- $164.36 / $282.94 / $1,175.81
| Professional | | $164.36 | $282.94 | $1,175.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.57 / $419.52 / $1,607.00
| Facility | | $269.57 | $419.52 | $1,607.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.66 / $400.10 / $531.85
| Facility | | $313.66 | $400.10 | $531.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,640.00 / $2,126.00
| Facility | | $1,204.00 | $1,640.00 | $2,126.00 |