- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.00 / $7,090.00 / $11,611.47
| Facility | | $5,091.00 | $7,090.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.64 / $805.69 / $1,724.65
| Professional | | $399.64 | $805.69 | $1,724.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $632.16 / $1,084.00 / $5,321.00
| Facility | | $632.16 | $1,084.00 | $5,321.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.11 / $1,293.30 / $2,197.38
| Facility | | $898.11 | $1,293.30 | $2,197.38 |
- 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 |