- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $4,964.00 / $7,119.04
| Facility | | $3,496.00 | $4,964.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.69 / $1,243.26 / $3,618.81
| Professional | | $809.69 | $1,243.26 | $3,618.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.40 / $2,143.50 / $14,242.22
| Facility | | $1,137.40 | $2,143.50 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,130.00 / $2,143.50 / $8,343.48
| Facility | | $1,130.00 | $2,143.50 | $8,343.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |