- 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
- $983.72 / $1,390.47 / $2,791.64
| Professional | | $983.72 | $1,390.47 | $2,791.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,456.40 / $2,925.61 / $6,945.09
| Facility | | $1,456.40 | $2,925.61 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.00 / $2,185.76 / $2,925.61
| Facility | | $1,621.00 | $2,185.76 | $2,925.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,711.00 / $5,854.53 / $7,407.10
| Facility | | $3,711.00 | $5,854.53 | $7,407.10 |