- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.05 / $964.91 / $2,049.87
| Professional | | $485.05 | $964.91 | $2,049.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $832.53 / $1,395.69 / $4,110.10
| Facility | | $832.53 | $1,395.69 | $4,110.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,168.10 / $1,508.92 / $1,890.34
| Facility | | $1,168.10 | $1,508.92 | $1,890.34 |
- 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 |