- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $5,549.00 / $11,100.08
| Facility | | $4,277.00 | $5,549.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.07 / $841.26 / $1,474.97
| Professional | | $525.07 | $841.26 | $1,474.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $675.49 / $1,274.81 / $5,847.00
| Facility | | $675.49 | $1,274.81 | $5,847.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $876.39 / $1,295.91 / $1,750.92
| Facility | | $876.39 | $1,295.91 | $1,750.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,854.53 / $7,305.00
| Facility | | $2,126.00 | $5,854.53 | $7,305.00 |