- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.35 / $5,108.00 / $10,506.16
| Facility | | $2,290.35 | $5,108.00 | $10,506.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.23 / $1,130.66 / $2,970.15
| Professional | | $763.23 | $1,130.66 | $2,970.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.09 / $2,220.37 / $12,371.41
| Facility | | $1,286.09 | $2,220.37 | $12,371.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,532.41 / $2,518.46 / $4,818.76
| Facility | | $1,532.41 | $2,518.46 | $4,818.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,523.00 / $11,869.99
| Facility | | $7,221.00 | $8,523.00 | $11,869.99 |