- 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
- $508.37 / $797.39 / $2,074.89
| Professional | | $508.37 | $797.39 | $2,074.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $838.72 / $1,361.44 / $7,896.02
| Facility | | $838.72 | $1,361.44 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.00 / $1,323.55 / $2,961.89
| Facility | | $1,052.00 | $1,323.55 | $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 |