- 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
- $520.72 / $830.58 / $1,656.47
| Professional | | $520.72 | $830.58 | $1,656.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.57 / $1,392.98 / $7,896.02
| Facility | | $897.57 | $1,392.98 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,058.00 / $1,497.11 / $2,961.89
| Facility | | $1,058.00 | $1,497.11 | $2,961.89 |
- 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 |