- 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
- $646.15 / $910.14 / $1,878.11
| Professional | | $646.15 | $910.14 | $1,878.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.65 / $1,926.85 / $7,104.12
| Facility | | $1,162.65 | $1,926.85 | $7,104.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,126.00 / $1,678.98 / $2,171.17
| Facility | | $1,126.00 | $1,678.98 | $2,171.17 |
- 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 |