- 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
- $404.49 / $637.64 / $1,385.02
| Professional | | $404.49 | $637.64 | $1,385.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $594.27 / $1,005.56 / $4,645.00
| Facility | | $594.27 | $1,005.56 | $4,645.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $845.32 / $1,105.69 / $1,597.11
| Facility | | $845.32 | $1,105.69 | $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 |