- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $8,042.03
| Facility | | $3,496.00 | $4,964.00 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.53 / $880.50 / $2,086.81
| Professional | | $545.53 | $880.50 | $2,086.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.04 / $1,448.54 / $7,896.02
| Facility | | $897.04 | $1,448.54 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $1,434.53 / $2,961.89
| Facility | | $1,089.00 | $1,434.53 | $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 |