- 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
- $55.51 / $97.56 / $185.70
| Professional | | $55.51 | $97.56 | $185.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.92 / $162.10 / $1,640.00
| Facility | | $97.92 | $162.10 | $1,640.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.72 / $134.84 / $176.38
| Facility | | $89.72 | $134.84 | $176.38 |
- 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 |