- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,393.00 / $5,817.59 / $10,506.16
| Facility | | $4,393.00 | $5,817.59 | $10,506.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.95 / $1,105.49 / $2,121.31
| Professional | | $635.95 | $1,105.49 | $2,121.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $958.94 / $1,836.31 / $14,525.55
| Facility | | $958.94 | $1,836.31 | $14,525.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,152.00 / $2,011.11 / $5,275.65
| Facility | | $1,152.00 | $2,011.11 | $5,275.65 |
- 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 |