- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,879.36 / $4,277.00 / $7,119.04
| Facility | | $1,879.36 | $4,277.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.10 / $923.49 / $2,002.80
| Professional | | $581.10 | $923.49 | $2,002.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $822.75 / $1,523.28 / $13,476.00
| Facility | | $822.75 | $1,523.28 | $13,476.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,158.32 / $1,652.36 / $8,518.27
| Facility | | $1,158.32 | $1,652.36 | $8,518.27 |
- 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 |