- 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
- $352.15 / $560.70 / $1,006.99
| Professional | | $352.15 | $560.70 | $1,006.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $627.79 / $1,013.64 / $8,586.74
| Facility | | $627.79 | $1,013.64 | $8,586.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $636.00 / $1,162.51 / $3,170.91
| Facility | | $636.00 | $1,162.51 | $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 |