- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $10,563.53
| Facility | | $4,146.00 | $4,964.00 | $10,563.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.97 / $337.74 / $652.02
| Professional | | $197.97 | $337.74 | $652.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.40 / $623.95 / $14,242.22
| Facility | | $391.40 | $623.95 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.00 / $647.61 / $5,661.05
| Facility | | $398.00 | $647.61 | $5,661.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |