- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,528.00 / $6,298.62 / $10,866.62
| Facility | | $3,528.00 | $6,298.62 | $10,866.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.34 / $646.71 / $1,648.38
| Professional | | $438.34 | $646.71 | $1,648.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $621.47 / $1,142.68 / $8,625.21
| Facility | | $621.47 | $1,142.68 | $8,625.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $882.13 / $1,469.35 / $6,479.99
| Facility | | $882.13 | $1,469.35 | $6,479.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $5,327.00 / $8,342.00
| Facility | | $1,770.00 | $5,327.00 | $8,342.00 |