- 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
- $906.04 / $1,455.47 / $2,692.67
| Professional | | $906.04 | $1,455.47 | $2,692.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.00 / $2,422.69 / $5,521.00
| Facility | | $1,285.00 | $2,422.69 | $5,521.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.64 / $1,913.58 / $2,807.92
| Facility | | $1,471.64 | $1,913.58 | $2,807.92 |
- 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 |