- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $9,185.68
| Facility | | $4,146.00 | $4,964.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.67 / $1,062.23 / $1,787.89
| Professional | | $555.67 | $1,062.23 | $1,787.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.10 / $1,657.76 / $8,972.49
| Facility | | $1,077.10 | $1,657.76 | $8,972.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,163.00 / $1,862.67 / $3,054.91
| Facility | | $1,163.00 | $1,862.67 | $3,054.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,711.00 / $6,110.41 / $8,342.00
| Facility | | $3,711.00 | $6,110.41 | $8,342.00 |