- 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
- $912.08 / $1,583.97 / $2,895.91
| Professional | | $912.08 | $1,583.97 | $2,895.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,438.98 / $2,731.05 / $14,396.24
| Facility | | $1,438.98 | $2,731.05 | $14,396.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,781.00 / $3,075.62 / $5,383.60
| Facility | | $1,781.00 | $3,075.62 | $5,383.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |