- 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
- $657.32 / $931.38 / $2,060.56
| Professional | | $657.32 | $931.38 | $2,060.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $940.98 / $1,987.65 / $9,874.90
| Facility | | $940.98 | $1,987.65 | $9,874.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $2,007.84 / $3,123.31
| Facility | | $1,089.00 | $2,007.84 | $3,123.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |