- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,012.00 / $6,298.62 / $11,100.08
| Facility | | $5,012.00 | $6,298.62 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.57 / $1,427.76 / $2,872.97
| Professional | | $817.57 | $1,427.76 | $2,872.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,607.07 / $2,428.21 / $14,525.55
| Facility | | $1,607.07 | $2,428.21 | $14,525.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.00 / $2,631.12 / $5,275.65
| Facility | | $1,517.00 | $2,631.12 | $5,275.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |