- 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
- $379.71 / $601.42 / $1,400.91
| Professional | | $379.71 | $601.42 | $1,400.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $543.61 / $1,010.97 / $4,645.00
| Facility | | $543.61 | $1,010.97 | $4,645.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $766.34 / $1,084.23 / $1,597.11
| Facility | | $766.34 | $1,084.23 | $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 |