- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $9,185.68
| Facility | | $4,146.00 | $4,964.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.51 / $739.54 / $1,262.53
| Professional | | $438.51 | $739.54 | $1,262.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $835.13 / $1,308.66 / $12,371.41
| Facility | | $835.13 | $1,308.66 | $12,371.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $797.00 / $1,441.20 / $4,818.76
| Facility | | $797.00 | $1,441.20 | $4,818.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |