- 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
- $728.41 / $1,253.72 / $2,120.09
| Professional | | $728.41 | $1,253.72 | $2,120.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.98 / $2,195.41 / $8,328.70
| Facility | | $1,335.98 | $2,195.41 | $8,328.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.00 / $2,149.90 / $2,571.84
| Facility | | $1,321.00 | $2,149.90 | $2,571.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |