- 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
- $692.83 / $1,159.67 / $3,147.43
| Professional | | $692.83 | $1,159.67 | $3,147.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,177.60 / $1,846.48 / $12,342.67
| Facility | | $1,177.60 | $1,846.48 | $12,342.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,381.29 / $1,846.48 / $6,616.19
| Facility | | $1,381.29 | $1,846.48 | $6,616.19 |
- 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 |