- 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
- $493.38 / $875.28 / $1,449.70
| Professional | | $493.38 | $875.28 | $1,449.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.31 / $1,470.19 / $29,141.12
| Facility | | $1,027.31 | $1,470.19 | $29,141.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $925.00 / $1,625.40 / $20,473.50
| Facility | | $925.00 | $1,625.40 | $20,473.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,542.00 / $12,871.00 / $16,293.00
| Facility | | $9,542.00 | $12,871.00 | $16,293.00 |