- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,066.00 / $7,119.04
| Facility | | $4,964.00 | $6,066.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.95 / $1,082.52 / $3,004.89
| Professional | | $693.95 | $1,082.52 | $3,004.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $909.42 / $1,553.55 / $3,936.91
| Facility | | $909.42 | $1,553.55 | $3,936.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.78 / $1,648.46 / $2,202.16
| Facility | | $1,120.78 | $1,648.46 | $2,202.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.00 / $5,847.00 / $7,856.00
| Facility | | $1,321.00 | $5,847.00 | $7,856.00 |