- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,463.36 / $9,185.68
| Facility | | $4,146.00 | $5,463.36 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.49 / $1,328.49 / $2,349.12
| Professional | | $852.49 | $1,328.49 | $2,349.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.29 / $2,240.04 / $14,242.22
| Facility | | $1,204.29 | $2,240.04 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,679.00 / $2,240.04 / $8,461.12
| Facility | | $1,679.00 | $2,240.04 | $8,461.12 |
- 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 |