- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,014.00 / $7,119.04 / $12,885.00
| Facility | | $4,014.00 | $7,119.04 | $12,885.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.46 / $1,518.81 / $3,610.06
| Professional | | $1,061.46 | $1,518.81 | $3,610.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.28 / $13,990.00 / $46,115.68
| Facility | | $1,982.28 | $13,990.00 | $46,115.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,726.62 / $2,254.16 / $2,807.92
| Facility | | $1,726.62 | $2,254.16 | $2,807.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,855.00 / $16,742.00 / $21,923.00
| Facility | | $12,855.00 | $16,742.00 | $21,923.00 |