- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $286.00 / $1,751.05 / $5,302.35
| Facility | | $286.00 | $1,751.05 | $5,302.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.00 / $1,600.00 / $1,600.00
| Professional | | $485.00 | $1,600.00 | $1,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,300.93 / $5,300.93 / $6,043.06
| Facility | | $5,300.93 | $5,300.93 | $6,043.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.00 / $541.00 / $3,840.03
| Facility | | $515.00 | $541.00 | $3,840.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,565.00 / $2,626.00 / $6,957.00
| Facility | | $1,565.00 | $2,626.00 | $6,957.00 |