- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,795.64 / $7,119.04
| Facility | | $2,218.00 | $3,795.64 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.63 / $611.54 / $925.65
| Professional | | $107.63 | $611.54 | $925.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.19 / $676.92 / $2,398.28
| Facility | | $161.19 | $676.92 | $2,398.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.60 / $810.46 / $1,182.97
| Facility | | $228.60 | $810.46 | $1,182.97 |
- 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 |