- 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
- $452.83 / $2,041.12 / $3,640.52
| Professional | | $452.83 | $2,041.12 | $3,640.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $827.43 / $2,889.54 / $6,558.00
| Facility | | $827.43 | $2,889.54 | $6,558.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.24 / $2,932.27 / $4,351.57
| Facility | | $975.24 | $2,932.27 | $4,351.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |