- 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
- $427.67 / $605.44 / $1,557.86
| Professional | | $427.67 | $605.44 | $1,557.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $753.46 / $1,318.44 / $6,945.09
| Facility | | $753.46 | $1,318.44 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $893.32 / $1,430.78 / $2,428.62
| Facility | | $893.32 | $1,430.78 | $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 |