- 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
- $1,042.82 / $1,759.14 / $3,156.73
| Professional | | $1,042.82 | $1,759.14 | $3,156.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,754.67 / $3,038.85 / $13,882.69
| Facility | | $1,754.67 | $3,038.85 | $13,882.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,723.62 / $2,554.73 / $3,300.29
| Facility | | $1,723.62 | $2,554.73 | $3,300.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |