- 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
- $134.54 / $988.19 / $1,322.13
| Professional | | $134.54 | $988.19 | $1,322.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.49 / $1,374.46 / $3,254.94
| Facility | | $269.49 | $1,374.46 | $3,254.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.90 / $1,512.26 / $2,222.53
| Facility | | $352.90 | $1,512.26 | $2,222.53 |
- 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 |