- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.50 / $1,060.79 / $2,164.71
| Professional | | $686.50 | $1,060.79 | $2,164.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $763.50 / $1,640.92 / $13,476.00
| Facility | | $763.50 | $1,640.92 | $13,476.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.92 / $1,752.31 / $5,874.92
| Facility | | $1,088.92 | $1,752.31 | $5,874.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |