- 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
- $787.34 / $1,224.56 / $2,826.24
| Professional | | $787.34 | $1,224.56 | $2,826.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,016.09 / $1,966.00 / $7,305.00
| Facility | | $1,016.09 | $1,966.00 | $7,305.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.67 / $1,840.67 / $2,388.06
| Facility | | $1,227.67 | $1,840.67 | $2,388.06 |
- 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 |