- 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
- $416.08 / $748.67 / $1,300.22
| Professional | | $416.08 | $748.67 | $1,300.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $653.54 / $1,104.50 / $5,567.24
| Facility | | $653.54 | $1,104.50 | $5,567.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $920.66 / $1,288.94 / $2,932.27
| Facility | | $920.66 | $1,288.94 | $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 |