- 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
- $644.53 / $920.23 / $1,769.65
| Professional | | $644.53 | $920.23 | $1,769.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.00 / $1,980.43 / $9,874.90
| Facility | | $1,015.00 | $1,980.43 | $9,874.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $1,980.43 / $3,123.31
| Facility | | $1,089.00 | $1,980.43 | $3,123.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,700.00 / $7,799.00 / $9,874.90
| Facility | | $4,700.00 | $7,799.00 | $9,874.90 |