- 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
- $384.00 / $590.78 / $1,004.92
| Professional | | $384.00 | $590.78 | $1,004.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.48 / $1,085.05 / $8,342.00
| Facility | | $515.48 | $1,085.05 | $8,342.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $658.00 / $1,197.75 / $3,093.19
| Facility | | $658.00 | $1,197.75 | $3,093.19 |
- 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 |