- 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
- $457.07 / $813.09 / $1,478.18
| Professional | | $457.07 | $813.09 | $1,478.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $894.78 / $1,354.21 / $8,586.74
| Facility | | $894.78 | $1,354.21 | $8,586.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $927.00 / $1,496.08 / $3,170.91
| Facility | | $927.00 | $1,496.08 | $3,170.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,382.33 / $6,608.00 / $8,953.00
| Facility | | $4,382.33 | $6,608.00 | $8,953.00 |