- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,227.00 / $5,463.36 / $7,120.36
| Facility | | $4,227.00 | $5,463.36 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.23 / $1,442.98 / $2,995.16
| Professional | | $926.23 | $1,442.98 | $2,995.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,284.99 / $2,126.39 / $6,036.00
| Facility | | $1,284.99 | $2,126.39 | $6,036.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,516.04 / $2,195.75 / $2,994.12
| Facility | | $1,516.04 | $2,195.75 | $2,994.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,739.00 / $7,405.00 / $10,320.00
| Facility | | $3,739.00 | $7,405.00 | $10,320.00 |