- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $7,120.36
| Facility | | $4,146.00 | $5,091.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.72 / $832.85 / $1,833.90
| Professional | | $523.72 | $832.85 | $1,833.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $767.60 / $1,389.98 / $6,267.00
| Facility | | $767.60 | $1,389.98 | $6,267.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.00 / $1,495.31 / $2,961.89
| Facility | | $1,042.00 | $1,495.31 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $4,663.00 / $7,305.00
| Facility | | $3,044.00 | $4,663.00 | $7,305.00 |