- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $8,632.35
| Facility | | $4,146.00 | $5,091.00 | $8,632.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.01 / $762.98 / $1,805.44
| Professional | | $500.01 | $762.98 | $1,805.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $626.53 / $1,314.05 / $7,123.00
| Facility | | $626.53 | $1,314.05 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $929.91 / $1,419.01 / $2,961.89
| Facility | | $929.91 | $1,419.01 | $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 |