- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,941.36 / $5,741.37 / $13,135.47
| Facility | | $1,941.36 | $5,741.37 | $13,135.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.57 / $945.48 / $2,017.82
| Professional | | $612.57 | $945.48 | $2,017.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $926.29 / $1,595.23 / $14,242.22
| Facility | | $926.29 | $1,595.23 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,128.00 / $1,595.23 / $8,470.25
| Facility | | $1,128.00 | $1,595.23 | $8,470.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |