- 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
- $482.50 / $766.80 / $1,731.94
| Professional | | $482.50 | $766.80 | $1,731.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.62 / $1,268.05 / $4,324.56
| Facility | | $821.62 | $1,268.05 | $4,324.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $921.92 / $1,165.21 / $1,537.15
| Facility | | $921.92 | $1,165.21 | $1,537.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $4,663.00 / $7,305.00
| Facility | | $3,044.00 | $4,663.00 | $7,305.00 |