- 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
- $1,242.61 / $1,888.61 / $3,219.01
| Professional | | $1,242.61 | $1,888.61 | $3,219.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,456.40 / $3,315.09 / $15,870.49
| Facility | | $1,456.40 | $3,315.09 | $15,870.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,039.84 / $2,952.68 / $4,003.89
| Facility | | $2,039.84 | $2,952.68 | $4,003.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |