- 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
- $1,474.50 / $2,352.78 / $4,018.77
| Professional | | $1,474.50 | $2,352.78 | $4,018.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,860.84 / $3,522.53 / $6,017.02
| Facility | | $1,860.84 | $3,522.53 | $6,017.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.64 / $2,305.56 / $4,342.78
| Facility | | $1,471.64 | $2,305.56 | $4,342.78 |
- 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 |