- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,966.66 / $4,911.00 / $9,185.68
| Facility | | $2,966.66 | $4,911.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.13 / $845.52 / $1,759.57
| Professional | | $553.13 | $845.52 | $1,759.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.93 / $1,422.63 / $7,123.00
| Facility | | $680.93 | $1,422.63 | $7,123.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,085.53 / $1,553.00 / $2,961.89
| Facility | | $1,085.53 | $1,553.00 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |