- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,463.36 / $7,120.36
| Facility | | $4,146.00 | $5,463.36 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.09 / $586.09 / $1,391.65
| Professional | | $371.09 | $586.09 | $1,391.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $621.29 / $986.40 / $4,645.00
| Facility | | $621.29 | $986.40 | $4,645.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $750.07 / $1,046.71 / $1,597.11
| Facility | | $750.07 | $1,046.71 | $1,597.11 |
- 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 |