- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $6,066.00 / $11,100.08
| Facility | | $4,277.00 | $6,066.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.53 / $1,055.44 / $2,868.04
| Professional | | $656.53 | $1,055.44 | $2,868.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,039.97 / $1,649.45 / $8,604.00
| Facility | | $1,039.97 | $1,649.45 | $8,604.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,273.00 / $1,610.81 / $2,106.81
| Facility | | $1,273.00 | $1,610.81 | $2,106.81 |
- 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 |