- 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
- $173.79 / $1,020.67 / $1,287.04
| Professional | | $173.79 | $1,020.67 | $1,287.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.83 / $978.42 / $2,190.41
| Facility | | $260.83 | $978.42 | $2,190.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $332.60 / $1,636.04 / $2,710.33
| Facility | | $332.60 | $1,636.04 | $2,710.33 |
- 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 |