- 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
- $617.50 / $937.95 / $2,571.25
| Professional | | $617.50 | $937.95 | $2,571.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.75 / $1,620.84 / $8,077.96
| Facility | | $812.75 | $1,620.84 | $8,077.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,264.77 / $1,738.54 / $2,961.89
| Facility | | $1,264.77 | $1,738.54 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |