- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,166.29 / $5,582.73 / $12,765.09
| Facility | | $2,166.29 | $5,582.73 | $12,765.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.76 / $250.00 / $300.08
| Professional | | $158.76 | $250.00 | $300.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,604.02 / $2,173.87 / $4,080.90
| Facility | | $1,604.02 | $2,173.87 | $4,080.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.44 / $1,242.00 / $4,317.00
| Facility | | $250.44 | $1,242.00 | $4,317.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.44 / $341.84 / $4,317.00
| Facility | | $250.44 | $341.84 | $4,317.00 |