- 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
- $441.45 / $780.89 / $1,732.65
| Professional | | $441.45 | $780.89 | $1,732.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.86 / $1,296.55 / $8,586.74
| Facility | | $796.86 | $1,296.55 | $8,586.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $951.00 / $1,452.66 / $3,170.91
| Facility | | $951.00 | $1,452.66 | $3,170.91 |
- 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 |