- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,227.00 / $5,463.36 / $7,120.36
| Facility | | $4,227.00 | $5,463.36 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.66 / $1,504.75 / $3,091.07
| Professional | | $954.66 | $1,504.75 | $3,091.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,278.58 / $2,041.31 / $5,557.91
| Facility | | $1,278.58 | $2,041.31 | $5,557.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.87 / $2,304.92 / $3,113.41
| Facility | | $1,579.87 | $2,304.92 | $3,113.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $6,588.00 / $10,320.00
| Facility | | $1,770.00 | $6,588.00 | $10,320.00 |