- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $9,185.68
| Facility | | $4,146.00 | $5,091.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.58 / $767.01 / $2,055.98
| Professional | | $397.58 | $767.01 | $2,055.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $683.23 / $1,204.26 / $8,073.49
| Facility | | $683.23 | $1,204.26 | $8,073.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $934.84 / $1,297.29 / $2,865.45
| Facility | | $934.84 | $1,297.29 | $2,865.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |