- 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
- $942.41 / $1,509.55 / $3,074.60
| Professional | | $942.41 | $1,509.55 | $3,074.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.20 / $2,486.62 / $20,063.05
| Facility | | $1,544.20 | $2,486.62 | $20,063.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,858.55 / $2,486.62 / $17,291.09
| Facility | | $1,858.55 | $2,486.62 | $17,291.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |