- 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
- $168.79 / $320.42 / $712.89
| Professional | | $168.79 | $320.42 | $712.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.20 / $713.71 / $8,586.74
| Facility | | $417.20 | $713.71 | $8,586.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $397.37 / $551.66 / $3,170.91
| Facility | | $397.37 | $551.66 | $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 |