- 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
- $2,096.02 / $3,323.61 / $4,246.08
| Professional | | $2,096.02 | $3,323.61 | $4,246.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,433.30 / $4,217.00 / $6,608.00
| Facility | | $1,433.30 | $4,217.00 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,526.14 / $5,252.11 / $7,044.35
| Facility | | $3,526.14 | $5,252.11 | $7,044.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |