- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $9,185.68
| Facility | | $4,146.00 | $4,964.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.27 / $1,304.97 / $2,306.82
| Professional | | $819.27 | $1,304.97 | $2,306.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,170.21 / $2,179.14 / $5,521.00
| Facility | | $1,170.21 | $2,179.14 | $5,521.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,334.83 / $1,913.58 / $2,426.00
| Facility | | $1,334.83 | $1,913.58 | $2,426.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $5,023.00 / $7,305.00
| Facility | | $3,044.00 | $5,023.00 | $7,305.00 |