- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.00 / $8,851.00 / $11,923.23
| Facility | | $5,091.00 | $8,851.00 | $11,923.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.29 / $6,832.45 / $9,056.19
| Professional | | $507.29 | $6,832.45 | $9,056.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $844.82 / $9,259.00 / $19,063.66
| Facility | | $844.82 | $9,259.00 | $19,063.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,082.13 / $11,520.42 / $16,672.18
| Facility | | $1,082.13 | $11,520.42 | $16,672.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $9,082.00 / $13,476.00
| Facility | | $1,770.00 | $9,082.00 | $13,476.00 |