- 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
- $512.25 / $724.36 / $1,901.07
| Professional | | $512.25 | $724.36 | $1,901.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $899.28 / $1,606.56 / $6,945.09
| Facility | | $899.28 | $1,606.56 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,070.46 / $1,598.00 / $2,428.62
| Facility | | $1,070.46 | $1,598.00 | $2,428.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,950.00 / $5,321.00 / $7,155.00
| Facility | | $2,950.00 | $5,321.00 | $7,155.00 |