- 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
- $754.40 / $1,064.97 / $1,990.15
| Professional | | $754.40 | $1,064.97 | $1,990.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.20 / $2,308.21 / $6,945.09
| Facility | | $1,275.20 | $2,308.21 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,290.41 / $1,953.11 / $2,498.94
| Facility | | $1,290.41 | $1,953.11 | $2,498.94 |
- 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 |