- 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
- $620.03 / $875.98 / $1,834.72
| Professional | | $620.03 | $875.98 | $1,834.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.27 / $1,948.56 / $6,945.09
| Facility | | $1,117.27 | $1,948.56 | $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 |