- 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
- $459.16 / $728.46 / $1,583.64
| Professional | | $459.16 | $728.46 | $1,583.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.08 / $1,208.02 / $4,645.00
| Facility | | $727.08 | $1,208.02 | $4,645.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $920.45 / $1,227.31 / $1,597.29
| Facility | | $920.45 | $1,227.31 | $1,597.29 |
- 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 |