- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,436.50 / $7,182.55 / $7,182.55
| Facility | | $2,436.50 | $7,182.55 | $7,182.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,648.00 / $2,648.00 / $4,573.00
| Professional | | $2,648.00 | $2,648.00 | $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
- $20,702.75 / $20,702.75 / $20,702.75
| Facility | | $20,702.75 | $20,702.75 | $20,702.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,663.00 / $2,530.00 / $2,530.00
| Facility | | $1,663.00 | $2,530.00 | $2,530.00 |