- 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
- $410.08 / $722.33 / $1,977.62
| Professional | | $410.08 | $722.33 | $1,977.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $718.07 / $1,167.36 / $12,371.41
| Facility | | $718.07 | $1,167.36 | $12,371.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $866.00 / $1,347.33 / $4,818.76
| Facility | | $866.00 | $1,347.33 | $4,818.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |