- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,911.00 / $9,185.68
| Facility | | $4,146.00 | $4,911.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.38 / $1,495.21 / $2,533.79
| Professional | | $924.38 | $1,495.21 | $2,533.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,283.54 / $2,719.05 / $9,495.24
| Facility | | $1,283.54 | $2,719.05 | $9,495.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,553.00 / $2,936.00 / $3,914.66
| Facility | | $1,553.00 | $2,936.00 | $3,914.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $7,091.00 / $10,320.00
| Facility | | $5,341.00 | $7,091.00 | $10,320.00 |