- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,295.30 / $9,580.87 / $11,207.91
| Facility | | $5,295.30 | $9,580.87 | $11,207.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.00 / $1,550.00 / $4,573.00
| Professional | | $447.00 | $1,550.00 | $4,573.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,151.00 / $2,151.00 / $2,151.00
| Facility | | $2,151.00 | $2,151.00 | $2,151.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,155.44 / $6,132.00 / $8,782.34
| Facility | | $1,155.44 | $6,132.00 | $8,782.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.00 / $143.00 / $143.00
| Facility | | $104.00 | $143.00 | $143.00 |