- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.60 / $623.38 / $1,396.72
| Professional | | $429.60 | $623.38 | $1,396.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $584.49 / $1,191.93 / $10,320.00
| Facility | | $584.49 | $1,191.93 | $10,320.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.00 / $1,395.30 / $4,164.35
| Facility | | $751.00 | $1,395.30 | $4,164.35 |
- 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 |