- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $7,090.00 / $11,611.47
| Facility | | $4,964.00 | $7,090.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.11 / $1,506.80 / $2,515.21
| Professional | | $891.11 | $1,506.80 | $2,515.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,418.13 / $2,365.73 / $9,874.90
| Facility | | $1,418.13 | $2,365.73 | $9,874.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,463.38 / $2,121.27 / $2,872.22
| Facility | | $1,463.38 | $2,121.27 | $2,872.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $7,091.00 / $10,320.00
| Facility | | $5,341.00 | $7,091.00 | $10,320.00 |