- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,382.72 / $4,505.00 / $7,120.36
| Facility | | $1,382.72 | $4,505.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.29 / $759.35 / $1,335.65
| Professional | | $439.29 | $759.35 | $1,335.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.00 / $1,392.90 / $10,320.00
| Facility | | $868.00 | $1,392.90 | $10,320.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.00 / $1,429.02 / $5,140.93
| Facility | | $868.00 | $1,429.02 | $5,140.93 |
- 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 |