- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,575.22 / $6,882.00 / $11,611.47
| Facility | | $4,575.22 | $6,882.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.03 / $1,000.43 / $1,759.22
| Professional | | $707.03 | $1,000.43 | $1,759.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,259.31 / $2,186.86 / $6,945.09
| Facility | | $1,259.31 | $2,186.86 | $6,945.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,478.92 / $1,953.11 / $2,428.62
| Facility | | $1,478.92 | $1,953.11 | $2,428.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |