- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,298.62 / $8,217.00
| Facility | | $4,964.00 | $6,298.62 | $8,217.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.72 / $1,254.27 / $2,136.37
| Professional | | $688.72 | $1,254.27 | $2,136.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,367.49 / $2,136.14 / $13,882.69
| Facility | | $1,367.49 | $2,136.14 | $13,882.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,144.86 / $1,701.15 / $2,224.98
| Facility | | $1,144.86 | $1,701.15 | $2,224.98 |
- 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 |