- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.73 / $1,530.81 / $2,586.06
| Professional | | $900.73 | $1,530.81 | $2,586.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,645.50 / $2,678.10 / $12,371.41
| Facility | | $1,645.50 | $2,678.10 | $12,371.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.00 / $2,956.11 / $4,818.76
| Facility | | $1,650.00 | $2,956.11 | $4,818.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,700.00 / $7,799.00 / $10,320.00
| Facility | | $4,700.00 | $7,799.00 | $10,320.00 |