- 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
- $2,075.11 / $3,285.21 / $4,205.45
| Professional | | $2,075.11 | $3,285.21 | $4,205.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,433.30 / $4,191.66 / $6,608.00
| Facility | | $1,433.30 | $4,191.66 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,494.10 / $5,256.34 / $6,995.31
| Facility | | $3,494.10 | $5,256.34 | $6,995.31 |
- 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 |