- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,091.00 / $7,119.04
| Facility | | $3,496.00 | $5,091.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.83 / $591.59 / $1,462.14
| Professional | | $383.83 | $591.59 | $1,462.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.16 / $1,046.63 / $7,123.00
| Facility | | $519.16 | $1,046.63 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $809.16 / $1,107.57 / $2,961.89
| Facility | | $809.16 | $1,107.57 | $2,961.89 |
- 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 |