- 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
- $742.21 / $1,231.56 / $2,163.98
| Professional | | $742.21 | $1,231.56 | $2,163.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.38 / $2,120.94 / $12,371.41
| Facility | | $1,115.38 | $2,120.94 | $12,371.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.00 / $2,440.25 / $4,818.76
| Facility | | $1,375.00 | $2,440.25 | $4,818.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $7,091.00 / $10,320.00
| Facility | | $5,341.00 | $7,091.00 | $10,320.00 |