- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $9,185.68
| Facility | | $4,146.00 | $4,964.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.07 / $751.79 / $1,473.65
| Professional | | $531.07 | $751.79 | $1,473.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $884.03 / $1,649.63 / $6,945.09
| Facility | | $884.03 | $1,649.63 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,112.01 / $1,598.00 / $2,428.62
| Facility | | $1,112.01 | $1,598.00 | $2,428.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |