- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,369.53 / $3,438.26 / $4,026.21
| Facility | | $2,369.53 | $3,438.26 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.10 / $1,085.11 / $1,085.11
| Professional | | $1,085.10 | $1,085.11 | $1,085.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,337.58 / $10,490.12 / $12,538.72
| Facility | | $6,337.58 | $10,490.12 | $12,538.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $680.00 / $680.00
| Facility | | $680.00 | $680.00 | $680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.00 / $7,228.00 / $12,680.00
| Facility | | $3,219.00 | $7,228.00 | $12,680.00 |