- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $9,185.68
| Facility | | $4,146.00 | $4,964.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.40 / $3,430.21 / $4,934.39
| Professional | | $402.40 | $3,430.21 | $4,934.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $746.28 / $5,275.65 / $13,086.08
| Facility | | $746.28 | $5,275.65 | $13,086.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,051.64 / $5,063.00 / $8,050.51
| Facility | | $1,051.64 | $5,063.00 | $8,050.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |