- 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
- $505.94 / $795.05 / $2,301.32
| Professional | | $505.94 | $795.05 | $2,301.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $839.32 / $1,389.31 / $7,123.00
| Facility | | $839.32 | $1,389.31 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.00 / $1,399.97 / $2,961.89
| Facility | | $1,052.00 | $1,399.97 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |