- 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
- $650.48 / $994.74 / $1,630.18
| Professional | | $650.48 | $994.74 | $1,630.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.91 / $1,769.04 / $7,350.19
| Facility | | $923.91 | $1,769.04 | $7,350.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,084.00 / $1,802.85 / $2,403.80
| Facility | | $1,084.00 | $1,802.85 | $2,403.80 |
- 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 |