- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,725.84 / $4,911.00 / $7,120.36
| Facility | | $3,725.84 | $4,911.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.88 / $660.71 / $1,714.79
| Professional | | $383.88 | $660.71 | $1,714.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.84 / $1,091.70 / $12,371.41
| Facility | | $602.84 | $1,091.70 | $12,371.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $686.00 / $1,259.73 / $4,818.76
| Facility | | $686.00 | $1,259.73 | $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 |