- 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
- $631.62 / $891.98 / $2,185.59
| Professional | | $631.62 | $891.98 | $2,185.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $964.28 / $1,908.09 / $7,104.12
| Facility | | $964.28 | $1,908.09 | $7,104.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.00 / $1,639.96 / $2,055.09
| Facility | | $1,285.00 | $1,639.96 | $2,055.09 |
- 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 |