- 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
- $117.05 / $169.43 / $494.59
| Professional | | $117.05 | $169.43 | $494.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.47 / $262.16 / $1,640.00
| Facility | | $171.47 | $262.16 | $1,640.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.47 / $262.16 / $364.98
| Facility | | $219.47 | $262.16 | $364.98 |
- 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 |