- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,091.00 / $7,119.04
| Facility | | $3,496.00 | $5,091.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.35 / $667.88 / $1,624.69
| Professional | | $421.35 | $667.88 | $1,624.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.07 / $1,126.95 / $7,896.02
| Facility | | $682.07 | $1,126.95 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.15 / $1,197.32 / $2,961.89
| Facility | | $846.15 | $1,197.32 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,700.00 / $7,405.00 / $9,874.90
| Facility | | $4,700.00 | $7,405.00 | $9,874.90 |