- 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
- $713.62 / $1,139.08 / $2,093.27
| Professional | | $713.62 | $1,139.08 | $2,093.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $913.72 / $1,732.03 / $5,847.00
| Facility | | $913.72 | $1,732.03 | $5,847.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.57 / $1,750.52 / $2,392.27
| Facility | | $1,167.57 | $1,750.52 | $2,392.27 |
- 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 |