- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,463.36 / $9,185.68
| Facility | | $4,146.00 | $5,463.36 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.42 / $702.17 / $1,425.05
| Professional | | $365.42 | $702.17 | $1,425.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $572.05 / $966.78 / $4,379.93
| Facility | | $572.05 | $966.78 | $4,379.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $806.40 / $1,164.47 / $1,750.65
| Facility | | $806.40 | $1,164.47 | $1,750.65 |
- 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 |