- 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
- $893.96 / $1,414.10 / $2,525.39
| Professional | | $893.96 | $1,414.10 | $2,525.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,365.24 / $2,368.73 / $7,896.02
| Facility | | $1,365.24 | $2,368.73 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,733.00 / $2,368.73 / $3,111.82
| Facility | | $1,733.00 | $2,368.73 | $3,111.82 |
- 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 |