- 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
- $759.68 / $1,205.00 / $3,365.91
| Professional | | $759.68 | $1,205.00 | $3,365.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,090.61 / $1,977.62 / $7,896.02
| Facility | | $1,090.61 | $1,977.62 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,474.09 / $1,977.62 / $2,961.89
| Facility | | $1,474.09 | $1,977.62 | $2,961.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,700.00 / $7,405.00 / $9,874.90
| Facility | | $4,700.00 | $7,405.00 | $9,874.90 |