- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.20 / $1,246.42 / $2,943.33
| Professional | | $792.20 | $1,246.42 | $2,943.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.23 / $1,838.45 / $5,321.00
| Facility | | $1,078.23 | $1,838.45 | $5,321.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,387.40 / $1,782.66 / $2,229.08
| Facility | | $1,387.40 | $1,782.66 | $2,229.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |