- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $7,120.36
| Facility | | $4,146.00 | $5,091.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.37 / $918.42 / $1,864.36
| Professional | | $546.37 | $918.42 | $1,864.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $910.36 / $1,426.31 / $7,896.02
| Facility | | $910.36 | $1,426.31 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,104.00 / $1,512.37 / $2,961.89
| Facility | | $1,104.00 | $1,512.37 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |