- 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
- $964.22 / $1,525.44 / $4,377.54
| Professional | | $964.22 | $1,525.44 | $4,377.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,382.13 / $2,497.96 / $6,034.22
| Facility | | $1,382.13 | $2,497.96 | $6,034.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,802.85 / $2,198.42 / $2,824.47
| Facility | | $1,802.85 | $2,198.42 | $2,824.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.00 / $4,663.00 / $7,305.00
| Facility | | $3,044.00 | $4,663.00 | $7,305.00 |