- 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
- $1,163.93 / $1,872.64 / $4,033.40
| Professional | | $1,163.93 | $1,872.64 | $4,033.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,574.59 / $2,758.34 / $16,293.00
| Facility | | $1,574.59 | $2,758.34 | $16,293.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,858.77 / $2,758.34 / $3,890.82
| Facility | | $1,858.77 | $2,758.34 | $3,890.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $12,871.00 / $16,293.00
| Facility | | $1,770.00 | $12,871.00 | $16,293.00 |