- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $7,120.36
| Facility | | $4,146.00 | $5,091.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.88 / $983.52 / $2,917.33
| Professional | | $610.88 | $983.52 | $2,917.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $849.76 / $1,616.25 / $14,242.22
| Facility | | $849.76 | $1,616.25 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,210.17 / $1,616.25 / $6,616.19
| Facility | | $1,210.17 | $1,616.25 | $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 |