- 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
- $670.51 / $1,082.83 / $2,315.52
| Professional | | $670.51 | $1,082.83 | $2,315.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.74 / $1,742.12 / $7,915.44
| Facility | | $1,008.74 | $1,742.12 | $7,915.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,149.00 / $1,949.20 / $3,162.53
| Facility | | $1,149.00 | $1,949.20 | $3,162.53 |
- 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 |