- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,754.40 / $6,309.57
| Facility | | $3,162.28 | $5,754.40 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,000.00 / $2,290.87
| Professional | | $954.99 | $1,000.00 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $1,905.46
| Facility | | $812.83 | $1,288.25 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $616.60 / $1,071.52
| Facility | | $524.81 | $616.60 | $1,071.52 |