- 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
- $1,068.96 / $1,714.17 / $2,969.16
| Professional | | $1,068.96 | $1,714.17 | $2,969.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,397.12 / $3,070.68 / $9,495.24
| Facility | | $1,397.12 | $3,070.68 | $9,495.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,763.84 / $3,070.68 / $3,914.66
| Facility | | $1,763.84 | $3,070.68 | $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 |