- 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
- $251.88 / $1,240.07 / $1,553.14
| Professional | | $251.88 | $1,240.07 | $1,553.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.22 / $2,086.82 / $8,857.49
| Facility | | $435.22 | $2,086.82 | $8,857.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $486.57 / $2,304.04 / $3,170.91
| Facility | | $486.57 | $2,304.04 | $3,170.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $7,091.00 / $10,320.00
| Facility | | $5,341.00 | $7,091.00 | $10,320.00 |