- 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
- $565.38 / $800.88 / $1,485.13
| Professional | | $565.38 | $800.88 | $1,485.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $889.21 / $1,756.74 / $6,945.09
| Facility | | $889.21 | $1,756.74 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,186.93 / $1,678.99 / $2,428.62
| Facility | | $1,186.93 | $1,678.99 | $2,428.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |