- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,778.89 / $7,119.04
| Facility | | $2,906.00 | $4,778.89 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.17 / $316.64 / $821.41
| Professional | | $214.17 | $316.64 | $821.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.38 / $563.22 / $4,871.77
| Facility | | $303.38 | $563.22 | $4,871.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $431.28 / $714.34 / $1,622.05
| Facility | | $431.28 | $714.34 | $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 |