- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $9,185.68
| Facility | | $4,146.00 | $4,964.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.32 / $612.32 / $1,073.08
| Professional | | $352.32 | $612.32 | $1,073.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $696.00 / $1,122.31 / $10,320.00
| Facility | | $696.00 | $1,122.31 | $10,320.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $696.00 / $1,142.07 / $3,972.29
| Facility | | $696.00 | $1,142.07 | $3,972.29 |
- 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 |