- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,042.03
| Facility | | $3,468.00 | $4,917.20 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.53 / $967.47 / $2,100.48
| Professional | | $619.53 | $967.47 | $2,100.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $824.33 / $1,550.91 / $7,305.00
| Facility | | $824.33 | $1,550.91 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,231.09 / $1,550.91 / $2,000.16
| Facility | | $1,231.09 | $1,550.91 | $2,000.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,305.00
| Facility | | $2,126.00 | $5,847.00 | $7,305.00 |