- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,693.00 / $5,817.59 / $7,943.37
| Facility | | $4,693.00 | $5,817.59 | $7,943.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.48 / $1,632.98 / $3,616.44
| Professional | | $981.48 | $1,632.98 | $3,616.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.28 / $2,335.30 / $14,812.97
| Facility | | $1,380.28 | $2,335.30 | $14,812.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,568.29 / $2,331.14 / $3,285.96
| Facility | | $1,568.29 | $2,331.14 | $3,285.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $9,082.00 / $13,476.00
| Facility | | $1,770.00 | $9,082.00 | $13,476.00 |