- 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
- $878.85 / $1,260.48 / $3,023.10
| Professional | | $878.85 | $1,260.48 | $3,023.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,634.86 / $13,990.00 / $46,115.68
| Facility | | $1,634.86 | $13,990.00 | $46,115.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,432.88 / $1,864.67 / $2,314.31
| Facility | | $1,432.88 | $1,864.67 | $2,314.31 |
- 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 |