- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,227.00 / $5,463.36 / $8,633.00
| Facility | | $4,227.00 | $5,463.36 | $8,633.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.13 / $1,140.33 / $2,123.71
| Professional | | $735.13 | $1,140.33 | $2,123.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $969.05 / $1,721.79 / $5,732.00
| Facility | | $969.05 | $1,721.79 | $5,732.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.85 / $1,749.62 / $2,335.06
| Facility | | $1,185.85 | $1,749.62 | $2,335.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $5,327.00 / $8,342.00
| Facility | | $1,770.00 | $5,327.00 | $8,342.00 |