- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,463.36 / $8,042.03
| Facility | | $3,496.00 | $5,463.36 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.91 / $962.93 / $1,997.47
| Professional | | $609.91 | $962.93 | $1,997.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $934.97 / $1,732.26 / $15,202.00
| Facility | | $934.97 | $1,732.26 | $15,202.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.41 / $1,734.10 / $10,445.10
| Facility | | $1,212.41 | $1,734.10 | $10,445.10 |
- 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 |