- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $5,549.00 / $11,100.08
| Facility | | $4,277.00 | $5,549.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.55 / $719.50 / $1,246.00
| Professional | | $463.55 | $719.50 | $1,246.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.20 / $1,219.86 / $5,847.00
| Facility | | $710.20 | $1,219.86 | $5,847.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $743.52 / $1,086.06 / $1,463.30
| Facility | | $743.52 | $1,086.06 | $1,463.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,305.00
| Facility | | $2,126.00 | $5,847.00 | $7,305.00 |