- 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
- $491.68 / $778.19 / $1,519.19
| Professional | | $491.68 | $778.19 | $1,519.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $599.89 / $1,328.56 / $8,165.52
| Facility | | $599.89 | $1,328.56 | $8,165.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $745.41 / $1,154.36 / $1,509.86
| Facility | | $745.41 | $1,154.36 | $1,509.86 |
- 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 |