- 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
- $798.33 / $1,076.79 / $2,428.01
| Professional | | $798.33 | $1,076.79 | $2,428.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.00 / $2,411.59 / $10,015.53
| Facility | | $1,089.00 | $2,411.59 | $10,015.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.57 / $2,550.86 / $4,188.66
| Facility | | $1,275.57 | $2,550.86 | $4,188.66 |
- 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 |