- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,211.00 / $6,086.00 / $12,916.00
| Facility | | $1,211.00 | $6,086.00 | $12,916.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,103.76 / $11,103.76 / $11,103.76
| Professional | | $11,103.76 | $11,103.76 | $11,103.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.00 / $2,811.71 / $3,347.28
| Facility | | $323.00 | $2,811.71 | $3,347.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,559.67 / $1,663.65 / $1,798.82
| Facility | | $1,559.67 | $1,663.65 | $1,798.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,681.00 / $5,811.00 / $10,057.00
| Facility | | $1,681.00 | $5,811.00 | $10,057.00 |