- 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
- $206.10 / $578.60 / $850.60
| Professional | | $206.10 | $578.60 | $850.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $355.23 / $701.75 / $5,321.00
| Facility | | $355.23 | $701.75 | $5,321.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $498.53 / $941.04 / $2,197.38
| Facility | | $498.53 | $941.04 | $2,197.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |