- 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
- $996.74 / $1,687.54 / $2,883.53
| Professional | | $996.74 | $1,687.54 | $2,883.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.82 / $3,033.46 / $14,396.24
| Facility | | $1,506.82 | $3,033.46 | $14,396.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,804.00 / $3,240.17 / $5,383.60
| Facility | | $1,804.00 | $3,240.17 | $5,383.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,523.00 / $11,869.99
| Facility | | $7,221.00 | $8,523.00 | $11,869.99 |