- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $7,120.36
| Facility | | $4,146.00 | $5,091.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.05 / $1,017.28 / $2,650.88
| Professional | | $614.05 | $1,017.28 | $2,650.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,044.84 / $1,632.35 / $12,342.67
| Facility | | $1,044.84 | $1,632.35 | $12,342.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,223.00 / $1,632.35 / $6,616.19
| Facility | | $1,223.00 | $1,632.35 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $11,869.99
| Facility | | $7,221.00 | $8,060.00 | $11,869.99 |