- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $9,185.68
| Facility | | $4,146.00 | $5,091.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.75 / $1,509.19 / $3,198.19
| Professional | | $1,065.75 | $1,509.19 | $3,198.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,646.62 / $3,304.88 / $6,945.09
| Facility | | $1,646.62 | $3,304.88 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,821.47 / $2,308.21 / $3,094.71
| Facility | | $1,821.47 | $2,308.21 | $3,094.71 |
- 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 |