- 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
- $383.27 / $542.75 / $1,083.23
| Professional | | $383.27 | $542.75 | $1,083.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $693.85 / $1,196.97 / $6,173.85
| Facility | | $693.85 | $1,196.97 | $6,173.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $802.60 / $1,294.15 / $2,428.62
| Facility | | $802.60 | $1,294.15 | $2,428.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $4,663.00 / $7,305.00
| Facility | | $3,044.00 | $4,663.00 | $7,305.00 |