- 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
- $388.61 / $626.61 / $1,118.93
| Professional | | $388.61 | $626.61 | $1,118.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $736.08 / $1,162.33 / $8,586.74
| Facility | | $736.08 | $1,162.33 | $8,586.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $706.00 / $1,282.70 / $3,170.91
| Facility | | $706.00 | $1,282.70 | $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 |