- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $7,120.36
| Facility | | $4,146.00 | $5,091.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.30 / $901.70 / $1,640.36
| Professional | | $573.30 | $901.70 | $1,640.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $760.85 / $1,573.76 / $7,123.00
| Facility | | $760.85 | $1,573.76 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,186.44 / $1,573.76 / $2,961.89
| Facility | | $1,186.44 | $1,573.76 | $2,961.89 |
- 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 |