- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.58 / $262.62 / $1,068.86
| Professional | | $64.58 | $262.62 | $1,068.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.30 / $269.47 / $552.04
| Facility | | $104.30 | $269.47 | $552.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.17 / $287.56 / $525.49
| Facility | | $121.17 | $287.56 | $525.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,640.00 / $2,126.00
| Facility | | $1,204.00 | $1,640.00 | $2,126.00 |