- 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
- $745.52 / $1,029.00 / $2,248.11
| Professional | | $745.52 | $1,029.00 | $2,248.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,073.01 / $2,281.88 / $9,874.90
| Facility | | $1,073.01 | $2,281.88 | $9,874.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,150.00 / $2,272.92 / $3,123.31
| Facility | | $1,150.00 | $2,272.92 | $3,123.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |