- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,518.41 / $1,996.40 / $6,853.30
| Facility | | $1,518.41 | $1,996.40 | $6,853.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.00 / $771.00 / $771.00
| Professional | | $771.00 | $771.00 | $771.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $439.81 / $488.68 / $4,411.72
| Facility | | $439.81 | $488.68 | $4,411.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,137.00 / $5,137.00 / $5,137.00
| Professional | | $5,137.00 | $5,137.00 | $5,137.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.24 / $1,401.00 / $4,915.00
| Facility | | $503.24 | $1,401.00 | $4,915.00 |