- 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
- $484.45 / $761.28 / $2,093.27
| Professional | | $484.45 | $761.28 | $2,093.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $802.44 / $1,337.33 / $7,896.02
| Facility | | $802.44 | $1,337.33 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.00 / $1,363.42 / $2,961.89
| Facility | | $1,026.00 | $1,363.42 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |