- 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
- $1,070.42 / $1,712.88 / $2,941.30
| Professional | | $1,070.42 | $1,712.88 | $2,941.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,392.97 / $2,672.92 / $5,521.00
| Facility | | $1,392.97 | $2,672.92 | $5,521.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.64 / $1,962.18 / $3,128.58
| Facility | | $1,471.64 | $1,962.18 | $3,128.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $5,023.00 / $7,305.00
| Facility | | $3,044.00 | $5,023.00 | $7,305.00 |