- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,733.21 / $7,506.00 / $16,290.45
| Facility | | $1,733.21 | $7,506.00 | $16,290.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.00 / $7,628.18 / $8,376.29
| Professional | | $3,162.00 | $7,628.18 | $8,376.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.00 / $1,463.45 / $3,944.80
| Facility | | $821.00 | $1,463.45 | $3,944.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,716.00 / $1,716.00 / $1,716.00
| Facility | | $1,716.00 | $1,716.00 | $1,716.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.00 / $821.00 / $821.00
| Facility | | $821.00 | $821.00 | $821.00 |