- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.45 / $663.71 / $1,164.00
| Professional | | $426.45 | $663.71 | $1,164.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.51 / $1,104.14 / $5,301.00
| Facility | | $578.51 | $1,104.14 | $5,301.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.27 / $1,207.17 / $1,750.65
| Facility | | $851.27 | $1,207.17 | $1,750.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |