- 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
- $460.13 / $871.17 / $1,510.78
| Professional | | $460.13 | $871.17 | $1,510.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $739.46 / $1,306.94 / $5,567.24
| Facility | | $739.46 | $1,306.94 | $5,567.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,101.89 / $1,422.11 / $2,932.27
| Facility | | $1,101.89 | $1,422.11 | $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 |