- 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
- $96.35 / $173.20 / $355.80
| Professional | | $96.35 | $173.20 | $355.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.22 / $228.44 / $1,300.00
| Facility | | $136.22 | $228.44 | $1,300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.29 / $229.36 / $319.12
| Facility | | $155.29 | $229.36 | $319.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.00 / $1,607.00 / $1,966.00
| Facility | | $1,026.00 | $1,607.00 | $1,966.00 |