- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.00 / $7,090.00 / $11,611.47
| Facility | | $5,091.00 | $7,090.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.31 / $1,173.93 / $3,122.27
| Professional | | $705.31 | $1,173.93 | $3,122.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,186.51 / $1,961.23 / $11,869.99
| Facility | | $1,186.51 | $1,961.23 | $11,869.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,417.00 / $1,969.19 / $5,383.60
| Facility | | $1,417.00 | $1,969.19 | $5,383.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $8,060.00 / $11,869.99
| Facility | | $7,221.00 | $8,060.00 | $11,869.99 |