- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,091.00 / $7,119.04
| Facility | | $3,496.00 | $5,091.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.46 / $4,187.67 / $5,909.03
| Professional | | $470.46 | $4,187.67 | $5,909.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.77 / $5,863.68 / $11,811.01
| Facility | | $707.77 | $5,863.68 | $11,811.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.38 / $6,632.67 / $11,811.01
| Facility | | $1,019.38 | $6,632.67 | $11,811.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $9,082.00 / $13,476.00
| Facility | | $1,770.00 | $9,082.00 | $13,476.00 |