- 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
- $594.27 / $841.48 / $1,944.45
| Professional | | $594.27 | $841.48 | $1,944.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.04 / $1,851.11 / $10,015.53
| Facility | | $906.04 | $1,851.11 | $10,015.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.71 / $2,011.86 / $4,188.66
| Facility | | $1,246.71 | $2,011.86 | $4,188.66 |
- 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 |