- 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
- $688.42 / $1,228.45 / $2,105.67
| Professional | | $688.42 | $1,228.45 | $2,105.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $929.67 / $1,831.49 / $8,342.00
| Facility | | $929.67 | $1,831.49 | $8,342.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,439.07 / $1,989.79 / $9,278.37
| Facility | | $1,439.07 | $1,989.79 | $9,278.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |