- 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
- $322.94 / $627.41 / $1,210.24
| Professional | | $322.94 | $627.41 | $1,210.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $522.32 / $888.77 / $5,567.24
| Facility | | $522.32 | $888.77 | $5,567.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.68 / $1,030.57 / $2,932.27
| Facility | | $706.68 | $1,030.57 | $2,932.27 |
- 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 |