- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,777.67 / $6,611.00 / $12,765.09
| Facility | | $3,777.67 | $6,611.00 | $12,765.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.56 / $2,011.84 / $3,397.30
| Professional | | $1,105.56 | $2,011.84 | $3,397.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,975.27 / $3,287.12 / $71,342.78
| Facility | | $1,975.27 | $3,287.12 | $71,342.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,135.00 / $3,645.06 / $55,111.78
| Facility | | $2,135.00 | $3,645.06 | $55,111.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,167.00 / $18,245.00 / $43,959.92
| Facility | | $16,167.00 | $18,245.00 | $43,959.92 |