- 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
- $1,235.14 / $1,927.04 / $3,601.15
| Professional | | $1,235.14 | $1,927.04 | $3,601.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.00 / $3,206.67 / $7,407.10
| Facility | | $1,711.00 | $3,206.67 | $7,407.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.00 / $2,383.30 / $3,493.23
| Facility | | $1,711.00 | $2,383.30 | $3,493.23 |
- 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 |