- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,693.00 / $5,549.00 / $7,943.37
| Facility | | $4,693.00 | $5,549.00 | $7,943.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.35 / $1,390.56 / $2,218.10
| Professional | | $879.35 | $1,390.56 | $2,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,121.01 / $2,116.44 / $8,604.00
| Facility | | $1,121.01 | $2,116.44 | $8,604.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,603.00 / $2,116.44 / $2,746.29
| Facility | | $1,603.00 | $2,116.44 | $2,746.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |