- 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
- $628.52 / $964.22 / $2,041.79
| Professional | | $628.52 | $964.22 | $2,041.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,070.96 / $1,671.12 / $14,242.22
| Facility | | $1,070.96 | $1,671.12 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,118.00 / $1,671.12 / $8,527.19
| Facility | | $1,118.00 | $1,671.12 | $8,527.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |