- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $7,119.04
| Facility | | $3,468.00 | $4,917.20 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.75 / $1,805.80 / $3,297.05
| Professional | | $1,178.75 | $1,805.80 | $3,297.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,610.60 / $2,717.50 / $7,896.02
| Facility | | $1,610.60 | $2,717.50 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,054.00 / $2,587.71 / $3,280.79
| Facility | | $2,054.00 | $2,587.71 | $3,280.79 |
- 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 |