- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.54 / $3,419.00 / $7,119.04
| Facility | | $2,125.54 | $3,419.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.16 / $978.95 / $1,957.68
| Professional | | $632.16 | $978.95 | $1,957.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $835.13 / $1,625.32 / $6,267.00
| Facility | | $835.13 | $1,625.32 | $6,267.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,131.00 / $1,735.82 / $2,961.89
| Facility | | $1,131.00 | $1,735.82 | $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 |