- 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
- $642.39 / $1,020.11 / $2,207.50
| Professional | | $642.39 | $1,020.11 | $2,207.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $942.05 / $1,557.35 / $5,946.43
| Facility | | $942.05 | $1,557.35 | $5,946.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.00 / $1,557.35 / $2,046.55
| Facility | | $1,271.00 | $1,557.35 | $2,046.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |