- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $7,120.36
| Facility | | $4,146.00 | $5,091.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.67 / $1,092.26 / $2,379.44
| Professional | | $685.67 | $1,092.26 | $2,379.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,150.27 / $1,827.44 / $11,139.12
| Facility | | $1,150.27 | $1,827.44 | $11,139.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,367.96 / $1,827.44 / $6,616.19
| Facility | | $1,367.96 | $1,827.44 | $6,616.19 |
- 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 |