- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,227.00 / $5,463.36 / $7,120.36
| Facility | | $4,227.00 | $5,463.36 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.07 / $962.40 / $1,941.64
| Professional | | $596.07 | $962.40 | $1,941.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.25 / $1,427.99 / $9,040.99
| Facility | | $847.25 | $1,427.99 | $9,040.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $956.84 / $1,413.38 / $2,000.16
| Facility | | $956.84 | $1,413.38 | $2,000.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $6,588.00 / $10,320.00
| Facility | | $1,770.00 | $6,588.00 | $10,320.00 |