- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.87 / $3,419.00 / $6,298.62
| Facility | | $519.87 | $3,419.00 | $6,298.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.47 / $722.98 / $1,394.54
| Professional | | $141.47 | $722.98 | $1,394.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $388.59 / $1,756.89 / $6,226.87
| Facility | | $388.59 | $1,756.89 | $6,226.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $366.18 / $1,650.37 / $2,411.10
| Facility | | $366.18 | $1,650.37 | $2,411.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,711.00 / $5,854.53 / $7,407.10
| Facility | | $3,711.00 | $5,854.53 | $7,407.10 |