- 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
- $810.96 / $1,291.30 / $2,543.46
| Professional | | $810.96 | $1,291.30 | $2,543.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,128.94 / $1,933.00 / $4,663.00
| Facility | | $1,128.94 | $1,933.00 | $4,663.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,326.08 / $1,953.41 / $2,612.17
| Facility | | $1,326.08 | $1,953.41 | $2,612.17 |
- 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 |