- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,012.00 / $6,405.00 / $10,255.42
| Facility | | $5,012.00 | $6,405.00 | $10,255.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.88 / $1,207.38 / $2,500.37
| Professional | | $780.88 | $1,207.38 | $2,500.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.50 / $1,850.78 / $4,535.92
| Facility | | $1,117.50 | $1,850.78 | $4,535.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.28 / $1,850.78 / $2,555.35
| Facility | | $1,300.28 | $1,850.78 | $2,555.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.00 / $5,847.00 / $7,856.00
| Facility | | $1,321.00 | $5,847.00 | $7,856.00 |