- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,468.00 / $4,917.20 / $8,042.03
| Facility | | $3,468.00 | $4,917.20 | $8,042.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.69 / $1,057.22 / $3,122.82
| Professional | | $742.69 | $1,057.22 | $3,122.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,287.11 / $3,027.45 / $11,495.00
| Facility | | $1,287.11 | $3,027.45 | $11,495.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,035.26 / $3,842.60 / $6,016.96
| Facility | | $2,035.26 | $3,842.60 | $6,016.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $11,869.99
| Facility | | $7,221.00 | $8,060.00 | $11,869.99 |