- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.55 / $1,276.40 / $2,642.94
| Professional | | $804.55 | $1,276.40 | $2,642.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,265.07 / $2,128.07 / $20,063.05
| Facility | | $1,265.07 | $2,128.07 | $20,063.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.12 / $2,128.07 / $16,982.16
| Facility | | $1,591.12 | $2,128.07 | $16,982.16 |
- 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 |