- 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
- $1,090.47 / $1,856.58 / $3,632.40
| Professional | | $1,090.47 | $1,856.58 | $3,632.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,664.62 / $2,940.38 / $8,572.06
| Facility | | $1,664.62 | $2,940.38 | $8,572.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.00 / $2,985.76 / $5,269.25
| Facility | | $2,416.00 | $2,985.76 | $5,269.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $11,869.99
| Facility | | $7,221.00 | $8,060.00 | $11,869.99 |