- 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
- $577.66 / $912.02 / $1,979.55
| Professional | | $577.66 | $912.02 | $1,979.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $925.17 / $1,576.23 / $6,695.24
| Facility | | $925.17 | $1,576.23 | $6,695.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,090.00 / $1,594.41 / $2,961.89
| Facility | | $1,090.00 | $1,594.41 | $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 |