- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,960.00 / $11,611.47
| Facility | | $4,964.00 | $6,960.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.10 / $949.86 / $1,603.23
| Professional | | $527.10 | $949.86 | $1,603.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,136.11 / $1,692.45 / $19,487.43
| Facility | | $1,136.11 | $1,692.45 | $19,487.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $858.30 / $1,339.83 / $1,483.51
| Facility | | $858.30 | $1,339.83 | $1,483.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,082.00 / $13,476.00 / $22,806.26
| Facility | | $9,082.00 | $13,476.00 | $22,806.26 |