- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $6,066.00 / $7,119.04
| Facility | | $4,277.00 | $6,066.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.29 / $1,108.93 / $2,713.12
| Professional | | $643.29 | $1,108.93 | $2,713.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.34 / $1,662.83 / $8,604.00
| Facility | | $1,061.34 | $1,662.83 | $8,604.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,239.19 / $1,596.36 / $2,081.61
| Facility | | $1,239.19 | $1,596.36 | $2,081.61 |
- 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 |