- 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
- $334.63 / $587.13 / $1,069.84
| Professional | | $334.63 | $587.13 | $1,069.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.00 / $1,050.53 / $20,604.33
| Facility | | $676.00 | $1,050.53 | $20,604.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.00 / $1,076.67 / $11,397.54
| Facility | | $676.00 | $1,076.67 | $11,397.54 |
- 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 |