- 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
- $725.99 / $1,225.08 / $2,076.76
| Professional | | $725.99 | $1,225.08 | $2,076.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,034.08 / $2,061.67 / $13,268.42
| Facility | | $1,034.08 | $2,061.67 | $13,268.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,281.00 / $2,302.38 / $5,383.60
| Facility | | $1,281.00 | $2,302.38 | $5,383.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,732.00 / $8,342.00
| Facility | | $4,217.00 | $5,732.00 | $8,342.00 |