- 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
- $493.79 / $755.43 / $1,806.83
| Professional | | $493.79 | $755.43 | $1,806.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $610.35 / $1,294.89 / $7,896.02
| Facility | | $610.35 | $1,294.89 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $949.84 / $1,401.96 / $2,961.89
| Facility | | $949.84 | $1,401.96 | $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 |