- 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
- $574.67 / $907.35 / $2,350.31
| Professional | | $574.67 | $907.35 | $2,350.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $949.93 / $1,579.08 / $7,896.02
| Facility | | $949.93 | $1,579.08 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $1,583.82 / $2,961.89
| Facility | | $1,089.00 | $1,583.82 | $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 |