- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.18 / $795.83 / $1,260.60
| Professional | | $159.18 | $795.83 | $1,260.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.70 / $929.18 / $1,878.29
| Facility | | $300.70 | $929.18 | $1,878.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.40 / $846.84 / $1,530.80
| Facility | | $347.40 | $846.84 | $1,530.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,775.00 / $3,482.00 / $5,454.00
| Facility | | $1,775.00 | $3,482.00 | $5,454.00 |