- 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
- $914.41 / $1,443.87 / $4,401.37
| Professional | | $914.41 | $1,443.87 | $4,401.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,225.68 / $2,607.16 / $11,869.99
| Facility | | $1,225.68 | $2,607.16 | $11,869.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,870.64 / $2,485.94 / $7,357.60
| Facility | | $1,870.64 | $2,485.94 | $7,357.60 |
- 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 |