- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,073.80 / $10,471.29
| Facility | | $1,659.59 | $4,073.80 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $3,548.13 / $3,630.78
| Professional | | $100.00 | $3,548.13 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,589.25 / $12,589.25 / $12,589.25
| Facility | | $12,589.25 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,801.89 / $5,888.44
| Facility | | $1,479.11 | $3,801.89 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,884.03 / $4,677.35
| Facility | | $1,548.82 | $2,884.03 | $4,677.35 |