- 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
- $426.32 / $2,035.32 / $3,569.68
| Professional | | $426.32 | $2,035.32 | $3,569.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.07 / $2,874.34 / $6,558.00
| Facility | | $776.07 | $2,874.34 | $6,558.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $915.80 / $2,932.27 / $4,344.72
| Facility | | $915.80 | $2,932.27 | $4,344.72 |
- 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 |