- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $6,298.62 / $12,885.00
| Facility | | $3,496.00 | $6,298.62 | $12,885.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.72 / $1,836.33 / $4,581.12
| Professional | | $1,162.72 | $1,836.33 | $4,581.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.82 / $2,824.40 / $7,305.00
| Facility | | $1,513.82 | $2,824.40 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,042.62 / $2,824.40 / $3,774.02
| Facility | | $2,042.62 | $2,824.40 | $3,774.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,305.00
| Facility | | $2,126.00 | $5,847.00 | $7,305.00 |