- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.46 / $632.15 / $2,051.06
| Professional | | $397.46 | $632.15 | $2,051.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $651.46 / $1,032.48 / $11,139.12
| Facility | | $651.46 | $1,032.48 | $11,139.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $772.00 / $1,127.00 / $6,616.19
| Facility | | $772.00 | $1,127.00 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |