- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $9,185.68
| Facility | | $4,146.00 | $5,091.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.05 / $838.25 / $1,483.57
| Professional | | $472.05 | $838.25 | $1,483.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.42 / $1,401.17 / $9,558.29
| Facility | | $927.42 | $1,401.17 | $9,558.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $939.00 / $1,547.45 / $3,162.53
| Facility | | $939.00 | $1,547.45 | $3,162.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $7,091.00 / $10,320.00
| Facility | | $5,341.00 | $7,091.00 | $10,320.00 |