- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.41 / $862.02 / $1,791.23
| Professional | | $490.41 | $862.02 | $1,791.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $771.02 / $1,287.73 / $4,217.00
| Facility | | $771.02 | $1,287.73 | $4,217.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.60 / $1,355.15 / $1,866.67
| Facility | | $1,060.60 | $1,355.15 | $1,866.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |