- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,042.03
| Facility | | $3,468.00 | $4,917.20 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.05 / $534.55 / $1,254.19
| Professional | | $310.05 | $534.55 | $1,254.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.50 / $940.08 / $8,586.74
| Facility | | $533.50 | $940.08 | $8,586.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $591.00 / $1,014.69 / $3,170.91
| Facility | | $591.00 | $1,014.69 | $3,170.91 |
- 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 |