- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,119.47 / $7,120.36
| Facility | | $4,146.00 | $5,119.47 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.81 / $1,187.49 / $2,830.96
| Professional | | $777.81 | $1,187.49 | $2,830.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,327.89 / $2,074.96 / $7,896.02
| Facility | | $1,327.89 | $2,074.96 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.00 / $2,074.96 / $2,961.89
| Facility | | $1,470.00 | $2,074.96 | $2,961.89 |
- 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 |