- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,382.00 / $8,477.27 / $19,276.96
| Facility | | $4,382.00 | $8,477.27 | $19,276.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.60 / $545.60 / $545.60
| Professional | | $545.60 | $545.60 | $545.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,604.02 / $2,173.87 / $4,080.90
| Facility | | $1,604.02 | $2,173.87 | $4,080.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.44 / $1,242.00 / $4,406.00
| Facility | | $250.44 | $1,242.00 | $4,406.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.00 / $1,775.00 / $4,406.00
| Facility | | $1,031.00 | $1,775.00 | $4,406.00 |