- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.83 / $580.20 / $1,113.68
| Professional | | $300.83 | $580.20 | $1,113.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $705.96 / $964.78 / $7,271.65
| Facility | | $705.96 | $964.78 | $7,271.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $705.96 / $985.48 / $3,170.91
| Facility | | $705.96 | $985.48 | $3,170.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $5,023.00 / $7,305.00
| Facility | | $3,044.00 | $5,023.00 | $7,305.00 |