- 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
- $193.77 / $283.41 / $1,423.37
| Professional | | $193.77 | $283.41 | $1,423.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.98 / $386.30 / $1,623.00
| Facility | | $255.98 | $386.30 | $1,623.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.54 / $423.59 / $658.91
| Facility | | $337.54 | $423.59 | $658.91 |
- 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 |