- 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
- $139.91 / $725.09 / $1,168.17
| Professional | | $139.91 | $725.09 | $1,168.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $286.98 / $864.79 / $1,393.28
| Facility | | $286.98 | $864.79 | $1,393.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.05 / $1,013.00 / $1,474.26
| Facility | | $326.05 | $1,013.00 | $1,474.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.00 / $1,623.00 / $2,126.00
| Facility | | $1,026.00 | $1,623.00 | $2,126.00 |