- 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
- $436.00 / $866.75 / $2,296.98
| Professional | | $436.00 | $866.75 | $2,296.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,051.67 / $2,043.79 / $6,306.00
| Facility | | $1,051.67 | $2,043.79 | $6,306.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,123.90 / $1,669.12 / $2,408.69
| Facility | | $1,123.90 | $1,669.12 | $2,408.69 |
- 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 |