- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,463.36 / $7,120.36
| Facility | | $4,146.00 | $5,463.36 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.86 / $1,249.65 / $2,924.98
| Professional | | $792.86 | $1,249.65 | $2,924.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.40 / $2,175.58 / $11,869.99
| Facility | | $1,372.40 | $2,175.58 | $11,869.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,594.00 / $2,132.88 / $5,383.60
| Facility | | $1,594.00 | $2,132.88 | $5,383.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $11,869.99
| Facility | | $7,221.00 | $8,060.00 | $11,869.99 |