- 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
- $792.87 / $1,106.59 / $2,422.91
| Professional | | $792.87 | $1,106.59 | $2,422.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,157.13 / $2,238.14 / $7,104.12
| Facility | | $1,157.13 | $2,238.14 | $7,104.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.00 / $1,846.80 / $2,411.10
| Facility | | $1,285.00 | $1,846.80 | $2,411.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.16 / $5,321.00 / $7,155.00
| Facility | | $3,006.16 | $5,321.00 | $7,155.00 |