- 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
- $763.68 / $1,067.69 / $2,507.12
| Professional | | $763.68 | $1,067.69 | $2,507.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.11 / $2,286.69 / $9,874.90
| Facility | | $1,271.11 | $2,286.69 | $9,874.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.00 / $2,286.69 / $3,123.31
| Facility | | $1,285.00 | $2,286.69 | $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 |