- 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
- $597.46 / $971.12 / $2,765.25
| Professional | | $597.46 | $971.12 | $2,765.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,021.97 / $1,616.71 / $12,342.67
| Facility | | $1,021.97 | $1,616.71 | $12,342.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,206.40 / $1,604.92 / $6,616.19
| Facility | | $1,206.40 | $1,604.92 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $11,139.12 / $18,346.22
| Facility | | $7,221.00 | $11,139.12 | $18,346.22 |