- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.01 / $1,628.39 / $3,364.87
| Professional | | $1,073.01 | $1,628.39 | $3,364.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,267.74 / $2,843.83 / $28,675.35
| Facility | | $1,267.74 | $2,843.83 | $28,675.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,142.67 / $3,034.70 / $25,996.02
| Facility | | $2,142.67 | $3,034.70 | $25,996.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |