- 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
- $471.36 / $740.70 / $1,591.59
| Professional | | $471.36 | $740.70 | $1,591.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $718.07 / $1,260.70 / $7,123.00
| Facility | | $718.07 | $1,260.70 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $934.00 / $1,316.00 / $2,961.89
| Facility | | $934.00 | $1,316.00 | $2,961.89 |
- 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 |