- 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
- $531.34 / $912.37 / $1,997.37
| Professional | | $531.34 | $912.37 | $1,997.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $863.26 / $1,521.34 / $5,567.24
| Facility | | $863.26 | $1,521.34 | $5,567.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.83 / $1,582.91 / $2,932.27
| Facility | | $1,152.83 | $1,582.91 | $2,932.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |