- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $9,906.40
| Facility | | $4,146.00 | $5,091.00 | $9,906.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.87 / $1,223.67 / $2,363.36
| Professional | | $644.87 | $1,223.67 | $2,363.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,523.27 / $2,417.17 / $20,740.72
| Facility | | $1,523.27 | $2,417.17 | $20,740.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,353.28 / $2,369.54 / $8,958.90
| Facility | | $1,353.28 | $2,369.54 | $8,958.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,523.00 / $11,869.99
| Facility | | $7,221.00 | $8,523.00 | $11,869.99 |