- 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
- $619.16 / $967.30 / $1,811.00
| Professional | | $619.16 | $967.30 | $1,811.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $843.00 / $1,768.15 / $7,350.19
| Facility | | $843.00 | $1,768.15 | $7,350.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $843.00 / $1,802.85 / $2,256.42
| Facility | | $843.00 | $1,802.85 | $2,256.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,687.93 / $6,034.22 / $8,342.00
| Facility | | $3,687.93 | $6,034.22 | $8,342.00 |