- 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
- $722.55 / $1,022.69 / $2,130.73
| Professional | | $722.55 | $1,022.69 | $2,130.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,231.36 / $2,182.19 / $9,874.90
| Facility | | $1,231.36 | $2,182.19 | $9,874.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.00 / $2,155.78 / $3,123.31
| Facility | | $1,285.00 | $2,155.78 | $3,123.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |