- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $6,066.00 / $11,100.08
| Facility | | $4,277.00 | $6,066.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.41 / $861.62 / $1,798.49
| Professional | | $556.41 | $861.62 | $1,798.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $861.22 / $1,318.97 / $1,700.71
| Facility | | $861.22 | $1,318.97 | $1,700.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,079.50 / $1,367.47 / $1,788.56
| Facility | | $1,079.50 | $1,367.47 | $1,788.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,151.00 / $1,775.00 / $3,560.25
| Facility | | $1,151.00 | $1,775.00 | $3,560.25 |