- 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
- $918.00 / $1,582.46 / $3,695.61
| Professional | | $918.00 | $1,582.46 | $3,695.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,555.56 / $2,464.23 / $14,242.22
| Facility | | $1,555.56 | $2,464.23 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,906.00 / $2,416.16 / $8,085.01
| Facility | | $1,906.00 | $2,416.16 | $8,085.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |