- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,042.03
| Facility | | $3,468.00 | $4,917.20 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.94 / $1,560.94 / $3,731.20
| Professional | | $988.94 | $1,560.94 | $3,731.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,371.96 / $2,520.14 / $7,305.00
| Facility | | $1,371.96 | $2,520.14 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,656.79 / $2,424.32 / $3,125.39
| Facility | | $1,656.79 | $2,424.32 | $3,125.39 |
- 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 |