- 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
- $635.39 / $897.48 / $1,966.14
| Professional | | $635.39 | $897.48 | $1,966.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.86 / $1,992.27 / $6,945.09
| Facility | | $1,141.86 | $1,992.27 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.00 / $1,821.47 / $2,428.62
| Facility | | $1,285.00 | $1,821.47 | $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 |