- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.00 / $6,750.00 / $11,611.47
| Facility | | $5,091.00 | $6,750.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.43 / $671.54 / $1,753.13
| Professional | | $422.43 | $671.54 | $1,753.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.70 / $1,130.29 / $7,896.02
| Facility | | $721.70 | $1,130.29 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.77 / $1,205.20 / $2,961.89
| Facility | | $847.77 | $1,205.20 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |