- 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
- $505.47 / $802.37 / $1,788.88
| Professional | | $505.47 | $802.37 | $1,788.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $859.28 / $1,349.71 / $12,342.67
| Facility | | $859.28 | $1,349.71 | $12,342.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,012.57 / $1,349.71 / $8,540.57
| Facility | | $1,012.57 | $1,349.71 | $8,540.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $11,869.99
| Facility | | $7,221.00 | $8,060.00 | $11,869.99 |