- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,248.79
| Facility | | $3,468.00 | $4,917.20 | $8,248.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.63 / $322.33 / $771.84
| Professional | | $211.63 | $322.33 | $771.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.20 / $702.66 / $7,984.00
| Facility | | $347.20 | $702.66 | $7,984.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.92 / $540.53 / $691.95
| Facility | | $363.92 | $540.53 | $691.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,611.00 / $3,915.00 / $5,454.00
| Facility | | $1,611.00 | $3,915.00 | $5,454.00 |