- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,671.00 / $3,617.00 / $6,329.00
| Facility | | $1,671.00 | $3,617.00 | $6,329.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $798.15
| Professional | | $287.56 | $287.56 | $798.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $448.92 / $1,704.86 / $2,700.74
| Facility | | $448.92 | $1,704.86 | $2,700.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.81 / $1,222.00 / $2,823.00
| Facility | | $304.81 | $1,222.00 | $2,823.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,086.00 / $2,017.00 / $3,268.00
| Facility | | $1,086.00 | $2,017.00 | $3,268.00 |