- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,964.00 / $8,042.03
| Facility | | $3,468.00 | $4,964.00 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.83 / $1,314.16 / $2,635.00
| Professional | | $809.83 | $1,314.16 | $2,635.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,103.78 / $2,126.51 / $8,572.06
| Facility | | $1,103.78 | $2,126.51 | $8,572.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.39 / $2,197.54 / $5,842.20
| Facility | | $1,481.39 | $2,197.54 | $5,842.20 |
- 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 |