- 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
- $563.91 / $896.63 / $1,975.58
| Professional | | $563.91 | $896.63 | $1,975.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.90 / $1,505.26 / $11,139.12
| Facility | | $886.90 | $1,505.26 | $11,139.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,127.56 / $1,505.26 / $6,616.19
| Facility | | $1,127.56 | $1,505.26 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,711.00 / $5,732.00 / $7,407.10
| Facility | | $3,711.00 | $5,732.00 | $7,407.10 |