- 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
- $644.12 / $1,079.15 / $1,890.22
| Professional | | $644.12 | $1,079.15 | $1,890.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,068.84 / $1,679.86 / $14,242.22
| Facility | | $1,068.84 | $1,679.86 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.93 / $1,679.86 / $9,104.70
| Facility | | $1,260.93 | $1,679.86 | $9,104.70 |
- 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 |