- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.64 / $931.10 / $2,228.48
| Professional | | $673.64 | $931.10 | $2,228.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $675.31 / $1,615.47 / $7,896.02
| Facility | | $675.31 | $1,615.47 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $1,672.79 / $2,961.89
| Facility | | $1,089.00 | $1,672.79 | $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 |