- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,042.03
| Facility | | $3,468.00 | $4,917.20 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.14 / $487.47 / $842.86
| Professional | | $282.14 | $487.47 | $842.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.00 / $868.30 / $9,495.24
| Facility | | $550.00 | $868.30 | $9,495.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.00 / $913.84 / $3,018.60
| Facility | | $550.00 | $913.84 | $3,018.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $7,091.00 / $10,320.00
| Facility | | $5,341.00 | $7,091.00 | $10,320.00 |