- 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
- $576.41 / $914.60 / $2,149.04
| Professional | | $576.41 | $914.60 | $2,149.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $857.64 / $1,537.56 / $7,896.02
| Facility | | $857.64 | $1,537.56 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,136.00 / $1,537.56 / $2,961.89
| Facility | | $1,136.00 | $1,537.56 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,180.89 / $6,840.79 / $9,751.77
| Facility | | $4,180.89 | $6,840.79 | $9,751.77 |