- 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
- $509.92 / $804.74 / $1,783.58
| Professional | | $509.92 | $804.74 | $1,783.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $872.28 / $1,340.20 / $6,267.00
| Facility | | $872.28 | $1,340.20 | $6,267.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,066.40 / $1,414.03 / $2,961.89
| Facility | | $1,066.40 | $1,414.03 | $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 |