- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,705.85 / $4,760.00 / $9,185.68
| Facility | | $1,705.85 | $4,760.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.37 / $797.15 / $1,549.70
| Professional | | $518.37 | $797.15 | $1,549.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $795.74 / $1,382.64 / $14,242.22
| Facility | | $795.74 | $1,382.64 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,041.96 / $1,425.35 / $8,548.87
| Facility | | $1,041.96 | $1,425.35 | $8,548.87 |
- 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 |