- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,098.00 / $11,100.08
| Facility | | $4,964.00 | $6,098.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.82 / $1,461.81 / $3,583.37
| Professional | | $963.82 | $1,461.81 | $3,583.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,371.72 / $2,793.51 / $23,351.66
| Facility | | $1,371.72 | $2,793.51 | $23,351.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,866.20 / $3,070.11 / $8,854.25
| Facility | | $1,866.20 | $3,070.11 | $8,854.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |