- 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
- $426.24 / $761.59 / $1,420.44
| Professional | | $426.24 | $761.59 | $1,420.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $679.78 / $1,224.47 / $5,567.24
| Facility | | $679.78 | $1,224.47 | $5,567.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $937.40 / $1,313.25 / $2,932.27
| Facility | | $937.40 | $1,313.25 | $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 |