- 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
- $44.47 / $98.37 / $208.40
| Professional | | $44.47 | $98.37 | $208.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.38 / $136.66 / $1,371.00
| Facility | | $97.38 | $136.66 | $1,371.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.34 / $134.44 / $187.11
| Facility | | $103.34 | $134.44 | $187.11 |
- 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 |