- 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
- $535.46 / $844.64 / $1,786.86
| Professional | | $535.46 | $844.64 | $1,786.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $937.55 / $1,361.62 / $4,645.00
| Facility | | $937.55 | $1,361.62 | $4,645.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $1,351.40 / $1,719.96
| Facility | | $1,089.00 | $1,351.40 | $1,719.96 |
- 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 |