- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $9,185.68
| Facility | | $4,146.00 | $4,964.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.50 / $268.32 / $1,681.62
| Professional | | $183.50 | $268.32 | $1,681.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.14 / $668.53 / $1,966.00
| Facility | | $438.14 | $668.53 | $1,966.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.14 / $586.35 / $809.08
| Facility | | $438.14 | $586.35 | $809.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,623.00 / $2,126.00
| Facility | | $1,204.00 | $1,623.00 | $2,126.00 |