- 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
- $576.07 / $896.88 / $2,086.81
| Professional | | $576.07 | $896.88 | $2,086.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $902.66 / $1,524.81 / $11,139.12
| Facility | | $902.66 | $1,524.81 | $11,139.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,132.81 / $1,510.61 / $6,616.19
| Facility | | $1,132.81 | $1,510.61 | $6,616.19 |
- 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 |