- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,463.36 / $10,204.23
| Facility | | $4,146.00 | $5,463.36 | $10,204.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.94 / $987.45 / $2,405.92
| Professional | | $619.94 | $987.45 | $2,405.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,054.96 / $1,647.22 / $7,896.02
| Facility | | $1,054.96 | $1,647.22 | $7,896.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.95 / $1,647.22 / $2,961.89
| Facility | | $1,232.95 | $1,647.22 | $2,961.89 |
- 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 |