- 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
- $139.12 / $980.76 / $1,559.11
| Professional | | $139.12 | $980.76 | $1,559.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.97 / $1,371.00 / $2,200.98
| Facility | | $340.97 | $1,371.00 | $2,200.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.18 / $1,539.00 / $2,200.98
| Facility | | $351.18 | $1,539.00 | $2,200.98 |
- 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 |