- 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
- $571.89 / $951.65 / $2,268.21
| Professional | | $571.89 | $951.65 | $2,268.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.35 / $2,188.19 / $6,854.80
| Facility | | $957.35 | $2,188.19 | $6,854.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.44 / $1,955.04 / $2,428.62
| Facility | | $1,491.44 | $1,955.04 | $2,428.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,711.00 / $5,854.53 / $7,407.10
| Facility | | $3,711.00 | $5,854.53 | $7,407.10 |