- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,091.00 / $7,119.04
| Facility | | $3,496.00 | $5,091.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.19 / $1,040.72 / $2,326.46
| Professional | | $655.19 | $1,040.72 | $2,326.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,112.18 / $1,735.01 / $7,896.02
| Facility | | $1,112.18 | $1,735.01 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,298.99 / $1,735.01 / $2,961.89
| Facility | | $1,298.99 | $1,735.01 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |