- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,234.00 / $3,795.64 / $7,119.04
| Facility | | $2,234.00 | $3,795.64 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.83 / $235.95 / $471.16
| Professional | | $156.83 | $235.95 | $471.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.64 / $405.85 / $4,871.77
| Facility | | $223.64 | $405.85 | $4,871.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.27 / $509.74 / $1,622.05
| Facility | | $312.27 | $509.74 | $1,622.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $4,663.00 / $7,305.00
| Facility | | $1,770.00 | $4,663.00 | $7,305.00 |