- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,066.00 / $7,119.04
| Facility | | $4,964.00 | $6,066.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.83 / $1,420.69 / $2,319.69
| Professional | | $903.83 | $1,420.69 | $2,319.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,158.15 / $1,966.00 / $4,663.00
| Facility | | $1,158.15 | $1,966.00 | $4,663.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,455.75 / $2,140.44 / $2,867.79
| Facility | | $1,455.75 | $2,140.44 | $2,867.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.00 / $5,847.00 / $7,856.00
| Facility | | $1,321.00 | $5,847.00 | $7,856.00 |