- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,091.00 / $7,119.04
| Facility | | $3,496.00 | $5,091.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.75 / $890.19 / $1,930.56
| Professional | | $560.75 | $890.19 | $1,930.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.32 / $1,496.39 / $14,242.22
| Facility | | $961.32 | $1,496.39 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,121.92 / $1,496.39 / $6,616.19
| Facility | | $1,121.92 | $1,496.39 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |