- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,463.36 / $7,887.41
| Facility | | $3,496.00 | $5,463.36 | $7,887.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.61 / $1,237.41 / $3,527.45
| Professional | | $776.61 | $1,237.41 | $3,527.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,326.99 / $2,095.39 / $7,896.02
| Facility | | $1,326.99 | $2,095.39 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.25 / $2,068.89 / $2,961.89
| Facility | | $1,547.25 | $2,068.89 | $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 |